cms_GA
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date ▼ | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10342 | 10342 | RIVERDALE CENTER | 115144 | 315 UPPER RIVERDALE ROAD | RIVERDALE | GA | 30274 | 2009-02-04 | 165 | D | 1 | 1 | UBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow their grievance process related to missing dentures for one (1) resident ("Q") on a sample of twenty-six (26) residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for resident "Q" revealed the resident had dentures. A Nursing Admission Assessment and Interdisciplinary Progress Note dated 12/01/08 also revealed the resident had upper and lower dentures on admission. On 02/02/09 at 12:52 p.m., the resident's morning care had been completed, and the resident was sitting in a Gerichair in their room. However, no dentures were observed in the resident's mouth at that time. On 02/03/09 at 12:13 p.m., Certified Nursing Assistant (CNA) "OO" located the bottom denture plate only in a cup in the resident's bedside table. On 02/03/09 at 12:18 p.m., the Social Services Director (SSD) stated that she thought a family member had asked her about a week-and-a-half ago about the resident's dentures and where they were. The SSD said it was on a Saturday and she was not able to come into the facility. She stated she called the resident's Power of Attorney (POA) the following Monday and left a message, and called the POA again this past Friday when asked by the family member again about the dentures, but was not able to reach the POA. The SSD said that she had no documentation of this, and at 5:35 p.m. added that in the event of missing items, the Grievance Policy and Procedure should be followed. On 02/04/09 at 8:00 a.m., Licensed Practical Nurse (LPN) Unit Manager "II" stated she did not know at what point the resident's upper dentures were lost. She added she thought a family member and/or SSD had asked about them, but could not remember when. At 10:00 a.m., the SSD stated she was able to reach the POA who verified that the resident had upper and lower dentures when admitted , and that they did not take the dentures home. Review of the facility's Res… | 2014-07-01 |
| 10437 | 10437 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2009-02-04 | 309 | D | 1 | 0 | 8IN411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer a medication as ordered by a physician for one (1) resident (#1) out of three (3) sampled residents. Findings include: Record review for Resident #1 revealed an Admission Nursing Evaluation of 12/23/2008 that indicated the resident had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Nurse's Note of 01/06/2009 at 7:00 a.m. documented that the resident had an elevated temperature of 103.7 degrees F, and a Nurse's Note of 01/08/2009 at 1:00 p.m. documented that the resident had an elevated temperature of 102.4 degrees F. However, there was no evidence to indicate that Tylenol was administered for these elevated temperatures of greater than 101 degrees F, per the physician's orders [REDACTED]. During an interview conducted on 02/04/2009 at 4:30 p.m., the Director of Nursing stated the nurses should have followed the temperature parameter per the physician's orders [REDACTED]. | 2014-07-01 |
| 10465 | 10465 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2009-02-04 | 514 | C | 1 | 0 | SLGD11 | Based on record review and staff interview, it was determined that the facility had failed to ensure that the Completed Care Tasks records for all residents in the facility, including Resident #1, were accurate. Findings include: A review of the Completed Care Task record for resident #1 revealed that there were time discrepancies documented on 10/23/08 and 10/24/08 in relation to when the actual time of care was provided. It was documented on 10/23/08 at 1:22 p.m. that the tasks of serving both breakfast and lunch were performed and the resident had eaten 100% of those meals. It was documented on 10/23/08 at 9:40 p.m. that the resident was out of the bed, in the wheelchair and in the dining room for supper. At 1:27 a.m. it was documented that the resident was bathed by washing his/her face. It was documented on 10/24/08, from 2:21 p.m. to 3:35 p.m., that various tasks were performed for the resident, including that the resident was repositioned in the chair, was "continent of urine?", had his/her face washed, voided three times, had 360 cubic centimeters (cc) of fluid, ate 100% of breakfast and 75% of lunch and had another 360 (cc) of fluid. Although on that date, it was documented in the Nurse's Notes that the resident had been out of the facility from 12:00 p.m. to 5:45 p.m., to the hospital getting his/her right arm x-rayed. Further, it was documented that at 3:39 a.m. the resident was bathed by washing his/her face. An interview conducted with the Assistant Director of Nursing on 2/4/09 at 3:15 p.m. revealed that the Completed Care Tasks Records for that resident and all of the other residents in the facility were from a computer system for charting care tasks. He/she stated that the certified nursing assistants (CNAs) used worksheets throughout the day in regards to the care tasks completed. Then at the end of their shifts, the CNAs' keyed that information into the computer system. He/she stated that the times that they keyed the information into the computer was not the "real time" that the tasks were comp… | 2014-07-01 |
| 10362 | 10362 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 157 | G | 1 | 0 | O2A612 | Based on record review and staff interview the facility failed to notified the resident's attending physician of blood glucose levels which would require medical intervention. This affected two (2) residents (#10 and #11) from a sample of eighteen (18) residents. The findings include: 1. Record review for resident #10 revealed sliding scale blood glucose monitoring was to be conducted four (4) times daily. The resident's insulin administration was based on this blood glucose monitoring. A review of the resident's Medication Administration Records (MAR) on 2/08/09, 2/09/09, 2/26/09 and 3/05/09 recorded the resident's blood glucose results were below 60. Review of the clinical record revealed the physician had not been notified. An interview with the facility's Director of Nursing (DON) on 3/17/09 at 9:00 a.m. confirmed that the resident's physician was not notified about the low blood sugar results. 2. Record review for resident #11 revealed sliding scale blood glucose monitoring was to be conducted two (2) times per day. The resident's insulin dosage was based on this blood glucose monitoring. A review of the resident's MAR indicated [REDACTED]. An interview with charge nurse LPN "AA" on 3/18/09 at 1:15 p.m. confirmed that physician was not notified about the high blood sugar results. The facility's Diabetic Care Protocol policy directed that the resident's physician be notified if the blood sugar results were less than 60 or more than 400. | 2014-07-01 |
| 10363 | 10363 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 333 | G | 1 | 0 | O2A611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that one (1) resident (#1), in a survey sample of ten (10) residents, was free of a significant medication error, regarding the failure to administer the prescribed dose of [MEDICATION NAME] intended to address the resident's extrapyramidal symptoms resulting from antipsychotic drug therapy. This represented actual harm, as the resident's extrapyramidal symptoms subsequently worsened. Findings include: Record review revealed a Nurse's Note of 09/05/2008 which documented that the resident had been admitted to the facility. A 09/06/2008 physician's orders [REDACTED]. The October and November 2008 Medication Records documented that the resident received doses of [MEDICATION NAME] every six (6) hours as ordered through 11/13/2008. An 11/13/2008 Nurse's Note at 12:25 p.m. documented that a physician's orders [REDACTED]. A Nurse's Note of 11/19/2008 at 11:10 a.m. documented that due to the resident's behavior, the physician had ordered to restart [MEDICATION NAME] 1 milligram every six hours, and to continue the [MEDICATION NAME] therapy. The November Medication Record documented that [MEDICATION NAME] therapy was discontinued on 11/13/2008 and restarted on 11/19/2008 as ordered, and that [MEDICATION NAME] therapy was initiated and administered as ordered from 11/13/2008 through 11/30/2008. The December 2008 Medication Record documented that the [MEDICATION NAME] and [MEDICATION NAME] therapy were administered as ordered from 12/01/2008 through 12/18/2008. Then, a 12/18/2008, 1:10 p.m. Nurse's Note documented that new physician's orders [REDACTED]. The December 2008 Medication Record documented that the [MEDICATION NAME] was changed to be administered on an as-needed basis, and the dose of [MEDICATION NAME] was increased to 75 milligrams twice daily, on 12/18/2008 as ordered, and documented that the resident received these drugs as ordered through 12/31/2008. A Nurse'… | 2014-07-01 |
| 10364 | 10364 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 498 | D | 1 | 0 | O2A611 | Based on review of a facility investigation and hospital record review, one (1) certified nursing assistant (CNA) ("XX"), of six (6) CNAs reviewed, was found to be legally intoxicated while performing duties. Findings include: Review of the Separation Notice for CNA "XX" dated 01/28/2009 revealed that the circumstance of the separation was a gross company violation. The Personnel Action form referencing CNA "XX" documented that during rounds, the charge nurse had smelled alcohol on the CNA and that when the CNA was sent to the hospital for alcohol testing, the CNA failed the test. The Alcohol Testing Form documented a positive result of 0.091 on 01/28/2009. | 2014-07-01 |
| 10414 | 10414 | CEDAR SPRINGS HEALTH AND REHAB | 115381 | 148 CASON ROAD | CEDARTOWN | GA | 30125 | 2009-02-11 | 151 | E | 1 | 1 | Y88V11 | Based on record review and resident and staff interviews, the facility failed to ensure that right to vote for three (3)residents ("B", "C" and "D") of four (4) residents in group interview. Findings include: During group interview conducted on 2/10/09 at 11:00a.m., three (3) residents "B', "C", and "D"complained that the facility did not assist them in voting in the presidential election in November, 2008. The residents indicated that they would have voted if given the opportunity. Resident "B" revealed that the social worker promised that she would assist him/her in completing an absentee ballot but the social worker never followed through. Review of the Facility Admission Packet revealed that under paragraph R., Voter Registration Information, the facility would assist residents to register to vote and obtain absentee ballots. Review of the State of Georgia Application for Voter Registration included instructions that revealed a copy of proper identification should be included with the application. Further review revealed that The postage is prepaid on the application and includes a pocket envelope that allows the application to be sealed with adhesive. Interview with the Administrator on 2/9/09 at 11:45am revealed that the Social Service Director registered several residents to vote but had not returned the registrations to the Elections Board in the appropriate time allocated. The Social Service Director also assisted some residents to vote but returned these ballots to the Elections Board unsealed, without the same signature as the registration, and without proper proof of identification. Further interview with the Administrator on 2/10/09 at 2pm revealed that the right to vote was covered during the admission process by the Social Services Director. Interview with the Activity Director on 2/10/09 at 8:45am revealed the residents are informed of their right to vote and if they are not registered to vote then registration or change of address form are obtained for them. The residents are assisted in completi… | 2014-07-01 |
| 10468 | 10468 | PINEWOOD MANOR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2009-02-18 | 314 | D | 1 | 0 | 9HB611 | Based on record review, observation, and staff interview, the facility failed to provide the necessary treatment, per a physician's treatment order, to promote the healing of a pressure sore for one (1) resident (#3) of ten (10) sampled residents. Findings include: Record review for Resident #3 revealed a 02/12/2009 wound assessment sheet which documented that the resident had an existing Stage III pressure ulcer on her/his coccyx, with the date of onset being 06/03/2008. The resident had a current physician's treatment order to pack the ulcer with collagen and to apply a foam dressing everyday until healed. Observation on 02/18/2009 at 10:55 a.m. during a wound/skin assessment, with Nurse "BB" and Certified Nursing Assistant "CC" in attendance, revealed that the resident did have a Stage III pressure sore on the coccyx, but had no wound dressing on the pressure sore. During an interview conducted at the time of this wound assessment on 02/18/2009 at 10:55 a.m., Nurse "BB" acknowledged that no dressing was covering the wound. During an interview also conducted at the time of this observation, Certified Nursing Assistant "CC" stated that when he/she provided incontinence care to the resident earlier in the morning of 02/18/2009 at 7:05 a.m., the resident did not have a wound dressing covering the pressure ulcer, but further acknowledged that he/she did not report to anyone that the dressing was off the wound. | 2014-07-01 |
| 10436 | 10436 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-02-25 | 281 | D | 1 | 0 | HC6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, family interview, and review of The Georgia Practical Nurses Practice Act, the facility failed to administer medications per professional standards and per facility protocol. Problems were identified for three (3) residents ("A", "B" and "C") from a survey sample of eight (8) residents. Findings Include: 1. Record review for Resident "A" revealed a January 2009 Minimum Data Set assessment which indicated that the resident had no problems with either short-term or long-term memory. Record review for Resident "A" also revealed a current physician's orders [REDACTED]. During an observation conducted on 02/25/2009 at 12:50 p.m., Nurse "BB" placed Tylenol tablets in a medication cup, walked to the resident's room, placed the medication cup on the resident's meal tray, and instructed the resident to take the medication when he/she was ready. The nurse was then observed to leave the resident's room before the resident ingested the medication. The resident was observed to take the medication without nurse oversight. During an interview with Resident "A" conducted on 02/25/2009 at 12:55 p.m., the resident confirmed that he/she was given Tylenol for pain and that the nurse left the medication on the meal tray to take when he/she was ready. The resident further stated the nurses never watch her/him take the medication, but rather always trust her/him to take the medicine. During an observation conducted at the time of this interview, the medication cup was observed to be sitting on the meal tray and empty. During an interview conducted on 02/25/2009 at 1:55 p.m., Nurse "BB" acknowledged that she handed Resident "A" the dose of Tylenol referenced above, but did not wait to observe the resident ingest the Tylenol. 2. Record review for Resident "C" revealed a December 2008 Minimum Data Set assessment which indicated that the resident had no short-term or long-term memory problems. Du… | 2014-07-01 |
| 10365 | 10365 | FAIRBURN HEALTH CARE CTR, INC | 115298 | 178 WEST CAMPBELLTON STREET | FAIRBURN | GA | 30213 | 2009-03-03 | 309 | E | 1 | 0 | TK3H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to do Accuchecks in accordance with physicians' orders for six (6) residents (#s 1, 2, 3, 4, 5 and 6) out of eleven (11) sampled residents. Findings include: 1. Record review for Resident #1 revealed that the Medication Record (MR) documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The resident also had a current physician's orders [REDACTED]. However, review of the resident's MR for the month of November 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 at 6:30 a.m. and on 11/13/2008 at 4:30 p.m. Review of the November 2008 and December 2008 MR revealed that for the dates of 11/25/2008, 12/01/2008, 12/03/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 2. Record review for Resident #2 revealed that the MR documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. However, review of the MR for the month of December 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled for the dates of 12/21/2008 and 12/26/2008 at 11:30 a.m., and for 12/10/2008 and 12/16/2008 for at 9:00 p.m. Additional review of this MR revealed that for the dates of 12/02/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 3. Record review for Resident # 3 revealed a current physician's orders [REDACTED]. However, review of the November and December 2008 MRs revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 and 12/22… | 2014-07-01 |
| 10475 | 10475 | PRUITTHEALTH - DECATUR | 115647 | 3200 PANTHERSVILLE ROAD | DECATUR | GA | 30034 | 2009-03-05 | 225 | D | 1 | 0 | BGXJ11 | Based on record review, staff and resident interview, the facility failed to conduct a thorough investigation of an allegation of physical abuse for one (1) resident (#4) from fourteen (14) sampled residents. The findings include: Record review revealed an investigation into two allegations of physical abuse towards resident #4. These investigations were initiated on 2/09/09 regarding an incident which happened on 2/06/09. The facility was made aware of the two allegations of physical abuse toward resident #4 by the family member of the resident and also by resident "D" who stated that they witnessed both events. The investigation included interviews and written statements from all staff that had been identified in the allegations and other staff members that could have witnessed or were aware of other incidents by the two nurses identified in the complaint. Review of the investigation into the two allegations of physical abuse against resident #4 and other allegations that were also noted by the family member and resident "D" revealed no documentation that interviewable residents were questioned about each allegation of physical abuse. In an interview with resident "L" on 3/05/09 at 4:22 p.m., he/she stated that they witnessed the incident when LPN "M" slapped the hand of resident #4. He/she stated that it happened about two weeks ago and that the nurse also told the resident to behave. In an interview with the Director of Nursing on 3/05/09 at 2:35 p.m. she indicated that all staff identified in the allegations of physical abuse were interviewed along with any staff that could have witnessed the incident. In an interview with the Administrator and Director of Nursing on 3/05/09 at 7:00 p.m., they stated that other residents that lived on the same floor with resident #4 were interviewed regarding the allegations of physical abuse. However, they confirmed that they did not interview other interviewable residents who frequently visited that floor and could have witnessed the incidents. | 2014-07-01 |
| 10404 | 10404 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-03-09 | 225 | E | 1 | 0 | FOUN11 | Based on staff interviews and review of facility reports/documentation, the facility failed to ensure that all allegations of abuse, neglect and mistreatment are reported immediately (within 24 hours) to the administrator of the facility and to other officials in accordance with State law through established procedures, including to the State survey and certification agency (SSA). The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the SSA) within 5 working days of the incident. Problems were identified for four (4) resident (#1, #6, #7, and #8 ) from eight ( 8) sampled residents. Findings include: Review of a Facility Grievance/Complaint Report Form revealed resident #8 reported on 2/25/2009 he/she had requested water from a Licensed Practical Nurse and the nurse refused to provide the water to the resident. This report nor findings of the investigation have not been reported to the SSA as of 3/23/2009. Review of a Facility Grievance/Complaint Report Form revealed resident #6 complained of verbal abuse and neglect by one certified nursing assistant (CNA) on 2/23/2009. Review of facility records revealed the facility did not report the alleged abuse to the SSA until 2/25/2009, two (2) days later. An interview with the Administrator conducted on 3/9/2009 at 2:00 p.m. revealed the administrator did not immediately report nor submit evidence of the investigation to the State Survey Agency within 5 working days as required. The Administrator said he/she would sent findings of the investigation today regarding the allegation. The Administrator additionally stated that she/he was not familiar with this regulatory requirement. A review of a Facility Incident Report Form dated 3/9/2009 for resident #7, revealed a CNA reported to the Administrator on 2/26/2009, that on 2/25/09 a licensed practical nurse has been cursing a resident during an emergency situation in which the resident was choking, and was no… | 2014-07-01 |
| 10458 | 10458 | CROSSVIEW CARE CENTER | 115541 | 402 E. BAY ST | PINEVIEW | GA | 31071 | 2009-03-11 | 323 | D | 1 | 0 | 5EVK11 | Based on record review, observation, and staff interview, the facility failed to develop or implement interventions to address the potential for accidents for two (2) residents (#1 and #2) from a total survey sample of six (6) residents. Findings include: 1. Record review for Resident #1 revealed Nurse's Note of 1/20/09 at 10:40 a.m. that the resident was found to have a hematoma over the left clavicle area. According to a Resident Assessment Protocol of 1/22/09, it was documented that the physician had felt that the resident had sustained the injury as the result of the siderails. According to the Nurse's Note of 1/25/09 at 2:10 p.m., the resident had been placed on a low bed with no siderails. The family members of this resident had objected to the low bed. The Nurse's Note of 1/26/09 at 1:00 p.m. documented that the resident had been placed back on a regular bed with bilateral siderails. This note also documented that bilateral siderails guards had been placed on the siderails. During an interview with licensed staff "AA" on 3/11/09 at 2:00 p.m., he/she stated that the resident would throw his/her legs over the siderails and would try to come through the siderails. This was also documented on a facility Incident Report of 1/20/09. A current Resident Care Plan entry indicated that the resident was at risk for falls. However, further record review, to include review of this Care Plan, revealed no evidence to indicate that, after 1/26/09, that the facility had evaluated the use of siderails as a potential accident hazard for this resident or to develop interventions to address the resident's attempts to come over the siderails Observations of the resident on 3/10/09 at 5:40 p.m. and on 3/11/09 at 2:00 p.m. revealed that he/she was on the bed with both siderails up and with no protective coverings or siderail guards. 2. Resident #2 was identified on the careplan as being at increased risk for skin impairment with an intervention added to the care plan on 11/6/08 to apply arm sleeves bilaterally to decrease risk fo… | 2014-07-01 |
| 10491 | 10491 | PRUITTHEALTH - OLD CAPITOL | 115681 | 310 HIGHWAY #1 BYPASS | LOUISVILLE | GA | 30434 | 2009-03-19 | 284 | E | 1 | 0 | US8H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop post-discharge plans of care to address the continuing care needs after discharge for five (5) residents (#2, #3, #4, #5 and #7) in a survey sample of seven (7) residents. Findings include: 1. Record review for Resident #7 revealed a Discharge Summary Form which documented that the resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This Discharge Summary Form also documented that while in the facility, the resident had received [MEDICATION NAME] anticoagulant drug therapy, and that the resident had been subsequently discharged to home with the family on 02/27/2009. A physician's orders [REDACTED]. However, further record review, to include review of the facility's Discharge Plan Of Care Form and the Discharge Summary Form, revealed no evidence to indicate that discharge planning had been done and that information and training regarding the resident's post-discharge continuing care needs, to include diet and drug therapy, had been provided. During an interview conducted on 03/19/2009 at 12:45 p.m., Social Services Staff "AA" acknowledged that he was uncertain of follow-up regarding the discharge. 2. Record review for Resident #2 revealed a 09/17/2008 Minimum Data Set (MDS) assessment which indicated that the resident had a [DIAGNOSES REDACTED]. While in the facility, physicians' orders specified for the resident to receive oxygen therapy, and drugs including [MEDICATION NAME] and Fordel Inhaler. A Discharge Summary Form documented that while in the facility, the resident had received oxygen on an as-needed basis, and that the resident was discharged from the facility on 02/12/2009 to a personal care home. However, further record review, to include review of the facility's Discharge Plan Of Care Form and Discharge Summary Form, revealed no evidence to indicate that discharge planning had been done and that information and training regarding t… | 2014-07-01 |
| 10402 | 10402 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-03-25 | 365 | K | 1 | 0 | 3LZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, facility document review, and staff interview, the facility failed to ensure that six (6) residents ("A", #1, #2, #4, #5 and #7) who had been assessed to need thickened liquids, on the survey sample of nine (9) residents, received thickened liquids to meet their individual needs. The failure of staff to ensure that these residents received thickened liquids represented the likelihood for serious harm for these residents. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 25, 2009, and continues. Findings include: 1. Record review for Resident "A" revealed that the March 2009 physician's orders [REDACTED]. The resident's current Interdisciplinary Care Plan referenced a 12/17/2008 entry identifying the resident to be a nutritional risk, with the Approaches including the provision of thickened liquids as ordered. However, the resident's current Nursing Assistant Care Card failed to indicate that the resident was to receive thickened liquids. During an observation conducted on 03/25/2009 at 8:50 a.m., Resident "A" was observed to be seated in a wheelchair in his/her room by his/her bed. During this observation, a cup containing unthickened water was sitting on an over-bed table directly in front of the resident within his/her reach, and a pitcher of unthickened water was sitting on the window sill to the right of the resident, within the resident's reach. During an interview conducted at the time of the 03/25/2009, 8:50 a.m. observation referenced above, Resident "A" indicated that the unthickened water was his/hers. During an additional observation conducted on 03/25/2009 at 9:40 a.m., Certified Nursing Assistant (CNA) "CC" was observed providing the resident a pitcher containing unthickened water. During an interview with CNA "CC" conducted on 03/25/2009 at 2:30 p.m., CNA "CC" stated that earlier in the day, she had filled Resid… | 2014-07-01 |
| 10403 | 10403 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-03-25 | 282 | K | 1 | 0 | 3LZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that three (3) residents ("A", #4 and #7) who had been assessed and care planned to receive thickened liquids, on the survey sample of nine (9) residents, received thickened liquids per their care plans. The failure of staff to ensure that these residents received thickened liquids represented the likelihood for serious harm for these residents. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 25, 2009, and continues. Findings include: 1. Record review for Resident "A" revealed that the March 2009 physician's orders [REDACTED]. However, during an observation conducted on 03/25/2009 at 8:50 a.m., Resident "A" was observed to be seated in a wheelchair in his/her room by his/her bed. A cup containing unthickened water was sitting on an over-bed table directly in front of the resident within his/her reach, and a pitcher of unthickened water was sitting on the window sill, within the resident's reach. During an interview conducted at the time of the 03/25/2009, 8:50 a.m. observation referenced above, Resident "A" indicated that the unthickened water was his/hers. During an observation conducted on 03/25/2009 at 9:40 a.m., Certified Nursing Assistant (CNA) "CC" was observed providing the resident a pitcher containing unthickened water. Cross refer to F365, example 1, for more information regarding Resident "A". 2. Record review for Resident #7 revealed a March 2009 Dysphagia Initial Plan Of Treatment (Evaluation) which documented that the resident had a [DIAGNOSES REDACTED]. However, during observations conducted on 03/25/2009 at 08:51 a.m., 12:55 p.m., and 2:15 p.m., the resident was observed in the room in the bed, and a water pitcher containing unthickened water was observed on the cabinet located directly in front of the resident's bed. Cross refer to F365, example 2, for more… | 2014-07-01 |
| 10473 | 10473 | AZALEA HEALTH AND REHABILITATION | 115642 | 300 CEDAR ROAD | METTER | GA | 30439 | 2009-03-31 | 364 | E | 1 | 0 | ZVRN11 | Based on resident interview and a test tray, the facility failed to serve foods at the proper temperature for four (4) residents of ten (10) sampled residents. Findings include: During an interview conducted on 03/31/2009 at 10:30 a.m., Resident "D" stated that the food that was served was cold, and that staff did not ask to reheat the food. During an interview conducted on 03/31/2009 at 10:05 a.m., Resident "A"stated the food that was served earlier that morning was cold and that the three (3) meals served the previous day were all cold. Also, the resident stated that the food had always been cold since he/she had lived in the facility. Resident "B" stated during an interview conducted on 03/31/2009 at 10:20 a.m. that the food was sometimes cold and that staff never asked if they could reheat the food. Resident "C" stated during an interview conducted on 03/31/2009 at 10:55 a.m. that the food was always cold at breakfast. The surveyor was served a test tray at 12:15 p.m. on 03/31/2009, and the pork chop and gravy were only lukewarm. | 2014-07-01 |
| 10499 | 10499 | SPRING HARBOR AT GREEN ISLAND | 115716 | 200 SPRING HARBOR DRIVE | COLUMBUS | GA | 31904 | 2009-03-31 | 323 | G | 1 | 0 | 9H8311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and observation, the facility failed to ensure the safe use of a heating pad for one (1) resident ("A") from a survey sample of seven (7) residents. This failure resulted in actual harm, a second degree burn, to the resident. Findings include: Record review for Resident "A" revealed a March 2009 Minimum Data Set assessment which indicated that the resident had no short-term or long-term memory problems. A 03/19/2009, 4:20 p.m. physician's orders [REDACTED]. A Daily Skilled Nurses Note of 03/19/2009 at 10:00 p.m. documented that a heating pad had been brought to the facility by the resident's spouse, and the March 2009 Medication Administration Record indicated to apply the heating pad to the resident's lower back every two-to-three hours for 20 minutes. During an interview with Nurse "AA" conducted on 03/30/2009 at 1:30 p.m., Nurse "AA" stated that the resident's family had brought a heating pad for the resident's use, and that the heating pad had been left in the resident's room for the resident to apply. During an interview with Resident "A" conducted on 03/30/2009 at 3:05 p.m., the resident stated that the heating pad had been applied most of the day of 03/20/2009. However, further record review revealed no evidence to indicate that facility staff had monitored the application or use of the heating pad throughout the day of 03/20/2009. During the 03/30/2009, 1:30 p.m. interview with Nurse "AA" referenced above, Nurse "AA" acknowledged that nursing staff had did not monitor the use and application of the heating pad throughout the day of 03/20/2009. A Daily Skilled Nurses Note of 03/20/2009 at 5:00 p.m. documented that a quarter-size blister had been noted to the resident's mid-back, with red, splotchy areas surrounding the blister, and that the nurse practitioner was notified. A 03/20/2009, 5:00 p.m. physician's orders [REDACTED]. twice daily until healed. During the 03/30/2009, … | 2014-07-01 |
| 10432 | 10432 | SUMMERHILL | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2009-04-01 | 223 | D | 1 | 0 | CVD511 | Based on record review, staff interview, and review of relevant facility documents, the facility failed to ensure that residents have the right to freedom from abuse, related to an incident of physical abuse for one (1) resident (#1) from a survey sample of six (6) residents. Findings include: Record review for Resident #1 revealed a 03/04/2009 Minimum Data Set assessment which indicated that the resident was assessed to have short-term and long-term memory deficits and impaired decision-making capacity. A Nurse's Note of 3/15/09 at 8:30 p.m. documented that the resident was very confused and combative on that date as evidenced by yelling and fighting. The Note further documented that the resident was attempting to go out of the door and the writer brought her back onto the hall. A Facility Incident Report Form dated 3/17/09 documented that on 3/15/2009 at 9:45 p.m., Certified Nursing Assistant (CNA) "BB" alleged that she witnessed Nurse "AA" slap Resident #1 and to tell the resident to "shut up". Nurse "AA" was suspended and an investigation was immediately begun. In a written signed statement dated 3/17/09 by CNA "AA", the CNA documented that on the evening of Sunday 3/15/09, the resident was really combative towards the roommate and when she and another CNA went into the room to intervene and/or assist with the situation, they were unsuccessful and Nurse "AA" came to assist. CNA "BB" further documented that shortly after this, she was coming out of another resident's room nearby and saw Nurse "AA" slap the resident in the face and tell him/her to "shut up". The CNA's statement further documented that Nurse "AA" pushed the resident in a wheelchair down to the nursing station where she tied the resident with a sheet. In a written statement by the Nurse "AA" dated 3/18/09, the nurse documented that on March 15, 2009, the resident was very agitated, confused and combative, and she was unable to calm the resident. In this same statement, Nurse "AA" documented that she did not remember or believe that she had hit th… | 2014-07-01 |
| 10433 | 10433 | SUMMERHILL | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2009-04-01 | 225 | D | 1 | 0 | CVD511 | Based on facility record review and staff interview, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the administrator of the facility for one (1) resident (#1) on a survey sample of six (6) residents. Findings include: A Facility Incident Report Form dated 3/17/09 at 9:30 p.m. documented that it was alleged to the Administrator on 3/17/09 at 9:30 p.m. that on 3/15/09 at 9:45 p.m., Certified Nursing Assistant (CNA) "BB" had witnessed a licensed nurse employee slap Resident #1 and to tell the resident to "shut up". Further record review revealed that although the facility had conducted a thorough investigation, and implemented corrective actions, regarding this alleged incident of abuse of 03/15/2009 once the Administrator was made aware of the allegation on 03/17/2009, CNA "BB" had failed to report the allegation immediately to the facility Administrator. The above findings were acknowledged during interview on 4/01/09 at approximately 4:00 p.m. with the Administrator, the Assistant Administrator, and the Director of Nursing. | 2014-07-01 |
| 10358 | 10358 | MANOR CARE REHABILITATION CENTER - MARIETTA | 115283 | 4360 JOHNSON FERRY PLACE | MARIETTA | GA | 30068 | 2009-04-03 | 315 | E | 1 | 0 | ENNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide incontinence care in a manner to prevent the spread of urinary tract infections for four (4) residents (#s 1, 2, 3 and 4), who were incontinent and were dependent on staff for toileting, on the survey sample of seven (7) residents. Findings include: 1. Record review for Resident #1 revealed a 03/18/2009 Minimum Data Set (MDS) assessment which indicated that the resident was incontinent of bowel and bladder and was totally dependent on staff for toilet use. During an observation of incontinence care provided to Resident #1 on 04/02/2009 at 7:10 p.m. by Certified Nursing Assistant (CNA) "AA", the CNA placed on gloves and proceeded to clean the resident's rectal area, but failed to clean the resident's front perinea area. The CNA continued to provide care to the resident wearing the soiled gloves used to clean the rectal area, placing a clean diaper and gown on the resident. 2. Record review for Resident #2 revealed a 03/06/2009 MDS assessment which indicated that the resident was incontinent of bowel and bladder and was totally dependent on staff for toilet use. During an observation of incontinence care provided to Resident #2 on 04/02/2009 at 7:25 p.m. by CNA "AA", the CNA placed on gloves prior to providing care, and cleaned the front perinea with a back-to-front wipe. Then, wearing the same gloves used to provide incontinence care, the CNA placed a clean diaper and gown on the resident and pulled the sheets up around the resident. 3. Record review for Resident #3 revealed a 01/06/2009 MDS assessment which indicated that the resident was frequently incontinent of bowel and bladder and required the extensive assistance of staff for toilet use. During an observation of CNA "BB" providing incontinence care to Resident #3 on 04/02/2009 at 7:45 p.m., after cleaning stool from the resident, the CNA placed cream on the resident's buttocks and rectal area, and t… | 2014-07-01 |
| 10360 | 10360 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-04-06 | 323 | G | 1 | 0 | 5ZN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility document review, the facility failed to ensure that two (2) residents (#s 1 and 3), on the survey sample of eight (8) residents, received adequate supervision during transfer and/or the provision of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: 1. Record review for Resident #3 revealed a 02/10/2009 Minimum Data Set (MDS) assessment which indicated that the resident was totally dependent on staff for transfers. A Care Plan entry of 02/12/2009 specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented extreme heat on the knee. This Note documented that the physician was called and gave an order to transfer the resident to the hospital emergency room for evaluation. A Nurse's Note of 03/28/2009 at 10:25 a.m. documented that the transport service had arrived and transported the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a splint on the right leg and a [DIAGNOSES REDACTED]. Review of the facility's investigation into this resident's injury revealed a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB". In this statement, CNA "BB" documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed when the CNA was attempting to turn the resident around and place him/her in the Geri-Chair. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. 2. Record review for Resident #1 revealed a 01/09/2009 MDS assessment which indicated that the resident was totally de… | 2014-07-01 |
| 10361 | 10361 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-04-06 | 282 | G | 1 | 0 | 5ZN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility document review, the facility failed to ensure that one (1) resident (#1), on the survey sample of eight (8) residents, was transferred in accordance with the resident's written plan of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: Record review for Resident #3 revealed a Care Plan entry of 02/12/2009 which specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented that the physician was called and gave an order to transfer the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a [DIAGNOSES REDACTED]. In a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB", this documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. Cross refer to F323, example 1, for more information regarding Resident #3. | 2014-07-01 |
| 10464 | 10464 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2009-04-09 | 157 | D | 1 | 1 | Q75711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and physician interview, it was determined that the facility failed to consult with one resident's (#16) physician regarding a significantly elevated body temperature from a total sample of 24 residents. Findings include: Review of the 4/4/09 nurses notes for resident #16 revealed that the resident had developed a fever of 102.2 at 5:53 p.m. Although 650 milligrams of [MEDICATION NAME] was administered to the resident at that time, staff failed to consult with the resident's attending physician regarding the elevated body temperature. During an interview with the resident's physician on 4/9/09 at 2:20 p.m., he stated that he would expect to be notified if the resident had a fever of 102.2. | 2014-07-01 |
| 10484 | 10484 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2009-04-15 | 314 | D | 1 | 1 | 9OJ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that two (2) residents with pressure sores (#3, #7) on a sample of twenty three (23) residents received the necessary care and treatment to promote healing, and prevention of new sores from developing. This failure was evidenced by the lack of communication related to the need for pressure sore treatment and problems with skin integrity. The findings include: Record review for resident #3 revealed she developed a Stage II pressure sore on her coccyx on 2/06/09. The most recent measurements for this pressure sore was done on 4/08/09. The pressure sore measured 1.0 by 1.0 by 0.4 centimeters in size. Observation of the pressure sore on 4/13/09 at 11:50 a.m. revealed that it did not have a dressing covering the area as ordered by the physician. Interview with the Certified Nursing Assistant (CNA) "BB" at that time indicated that he had performed pericare on the resident at approximately 9:00 a.m. on 4/13/09. At that time the dressing was not in place. He added that he did not report this concern to the Treatment Nurse. Interview with Treatment Nurse "AA" indicated that the resident's dressing was always off when she did the treatment. Another observation during pericare on 4/14/09 at 9:30 a.m. revealed the pressure sore dressing was not in place. Interview at that time with CNA "BB" indicated that when he did pericare at approximately 7:45 a. m., the resident did not have a dressing covering the pressure sore on her coccyx, and he reported this information to the nurse. Also at that time another Stage I pressure sore was seen on the residents right lower buttock. CNA "BB" stated this was not seen when he did the resident's pericare earlier. Another observation with Treatment Nurse "AA" on 4/14/09 at 10:25 a.m. revealed the dressing on the coccyx pressure sore was again not in place. Interview with the Treatment Nurse at that time indicated that she was not aware… | 2014-07-01 |
| 10485 | 10485 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2009-04-15 | 312 | D | 1 | 1 | 9OJ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that one (1) resident (#3) on a sample of twenty three (23) residents received personal hygiene and grooming of fingernails. The findings include: Record review revealed that resident #3 had a Minimal Data Set (MDS) assessment dated [DATE] that indicated the resident had long and short term memory loss, and required extensive care with personal hygiene and bathing. Observation of this resident on 4/13/09 at 2:40 p.m. and again on 4/14/09 at 10:30 a.m. revealed the resident had a brown/black substance under his/her fingernails on both hands. Interview with the Treatment Nurse on 4/14/09 at 10:30 a.m. revealed that this resident often eats with his/her hands and scratches his/herself. This is how his/her fingernails get dirty. Review of the facility's policy related to fingernail care indicated that nail care included daily cleaning and regular trimming. Dirt should be gently removed from around and under each fingernail with an orange stick. | 2014-07-01 |
| 10486 | 10486 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2009-04-15 | 309 | D | 1 | 1 | 9OJ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interview the facility failed to ensure that one (1) resident ("B") of twenty-three (23) sampled residents, received services recommended by a consulting physician to promote the healing of a fracture. The findings include: Resident "B" was admitted to the facility on [DATE] for therapy following a fractured femur. Review of the clinical record revealed a Physician's Consultation report dated 2/20/09 which recommended that the resident have an EBI Bone Stimulator for ten (10) hours every day. The Director of Nursing (DON) was interviewed on 4/15/09 at 10:15 a.m. and stated the facility did not provide bone stimulators. She was unable to provide any additional information about the recommendation. The Rehabilitation Department Manager was interviewed on 4/15/09 at 10:30 a.m. and stated a bone stimulator would have to be special ordered specific to the resident. He was not aware of resident "B" ever having a bone stimulator. Physical Therapist (PT) "FF" was interviewed on 4/15/09 at 10:35 a.m. and stated a company representative was called after the order was received, but the representative became ill and was unable to complete the order. PT "FF" further stated the facility did not follow-up on the bone stimulator with the company. A family member of resident "B" was interviewed on 4/15/09 at 10:45 a.m. and stated they had personally made sure the therapy department had the order for the bone stimulator when the resident returned to the facility on [DATE]. | 2014-07-01 |
| 10405 | 10405 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-04-16 | 328 | K | 1 | 0 | S3V211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, review of manufactures' patient manuel, and staff interviews, it was determined that the facility failed to properly administer oxygen therapy for two (2) residents, #1, and #2, and provide appropriate nursing care to prevent harm for resident #2, in a survey sample of twelve (12) residents. This resulted in harm to two resident and the likelihood of possible serious harm to (2) other residents who utilized oxygen concentrators and 4 other resident who received respiratory therapy. It was therefore determined that an immediate and serious threat to resident health and safety existed from March 30, 2009 until April 16, 2009, at which time the facility took action to correct the deficient practice and abate the jeopardy situation. Findings include: 1. The Progress Note dated 3/11/2009 revealed that resident #1 had [DIAGNOSES REDACTED]. The resident's care plan identified as a problem ineffective breathing pattern related to Chronic [MEDICAL CONDITION] Disease and to use oxygen as ordered. The physician's orders [REDACTED]. The Interdisciplinary Progress Notes on 3/30/09 documented that at 12:00 p.m. the certified nursing assistant went into the resident's room and found the resident to be blue and unresponsive. The notes documented the oxygen saturation (O2 sat) was 57% at 4 liters/minute of oxygen via nasal cannula, a blood pressure or pulse could not be obtained, no rise or fall of the resident's chest was observed; therefore facility staff notified the hospice nurse. The notes further documented at 1:00 p.m. the hospice nurse arrived and found the oxygen concentrator humidifier bottle not connected correctly and corrected the problem. It was further documented that the resident was monitored and at 3:00 p.m. the resident's skin was noted to be warm, dry and pink, with capillary refill in less than 3 seconds, the resident was alert and talking, and the O2 stat had improved to 94 % with oxygen being admin… | 2014-07-01 |
| 10406 | 10406 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-04-16 | 465 | D | 1 | 0 | S3V211 | Based on observations and staff interviews, it was determined that the facility failed to provide a safe, sanitary and comfortable area for laundry staff and the public. Findings include: During observation of the laundry area with the laundry supervisor at 10:30 a.m. on 4/15/2009, a large puddle of water was observed under the stairs. Observation of the wall behind the washer and dryer revealed several holes in the wall. In addition, towels and sheets were observed on the floor around the washer. Interview with staff "EE" on 4/15/2009 at 12:00 p.m., revealed that water would come into the laundry room during hard rains from the two corners of the wall behind the washer and dryer. In addition, stated that there were holes in the wall behind the washer and dryer that water came through into the laundry room. It was also observed and identified by staff person that the towels around the washer were wet with water. During the observations the laundry staff were running the washers and dryers. | 2014-07-01 |
| 10459 | 10459 | CROSSVIEW CARE CENTER | 115541 | 402 E. BAY ST | PINEVIEW | GA | 31071 | 2009-04-16 | 157 | D | 1 | 0 | XCY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility had failed to ensure that the physician was promptly consulted when there were changes in physical condition for two residents, Residents #1 and #2 from a sample of four residents. Findings include: 1. Record review for resident #1 revealed that he/she had a [MEDICAL CONDITION] of the left leg before his/her admission to the facility in 2005. According to the 12/12/08 (Friday) at 9:10 p.m. nursing note, he/she was found on the bathroom floor. He/she stated that the left knee popped but had no complaints of pain. The nursing note further documented that the physician would be notified the next office day (Monday). The resident had an order for [REDACTED]. He/she was medicated with [MEDICATION NAME] 100/650 for each of these complaints of pain. A nursing note of 12/15/08 at 12:30 a.m. documented that the resident complained of left upper extremity pain, was tender to touch and had swelling. It was noted that the resident cried out with pain at times. He/she was medicated with [MEDICATION NAME] again. However, licensed staff failed to notify the physician timely of this continued complaint of increasing severity of left knee pain until 12/15/08 at 9:00 a.m. (Monday). The resident was sent to the physician on 12/15/08 and was diagnosed with [REDACTED]. The above was acknowledged by licensed administrative staff "AA on 4/16/09 at 3:00 p.m.. 2. According to the 3/9/09 (Monday) at 10:00 a.m. nursing note for resident #2, it was noted that it had been been reported to this nurse that the resident had diarrhea over the weekend and the resident continued with diarrhea that morning. There was no documentation in the clinical record that the resident had experienced diarrhea or if anything was done to treat the diarrhea episodes of Saturday and Sunday (3/7 and 3/8/09). Documentation revealed the physician was not notified about the continued diarrhea until the morning of 3/9… | 2014-07-01 |
| 10460 | 10460 | CROSSVIEW CARE CENTER | 115541 | 402 E. BAY ST | PINEVIEW | GA | 31071 | 2009-04-16 | 314 | D | 1 | 0 | XCY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility had failed to provide the appropriate care for one resident with a pressure sore, Resident #3, from a sample of four residents: Findings include: According to the medical record Resident #3 had a history of [REDACTED]. According to the wound care clinic note of 12/16/08, it was documented that the right heel ulcer had healed in June of 2008. The resident had an order in place, at least since 9/08 and prior to 12/3/08, for [MEDICATION NAME] border to the right heel every three days and to pull the dressing back daily and check the status of the heel. Review of the documentation on the treatment record for 12/3/08 revealed a notation that the right heel had re-opened. The facility continued to use [MEDICATION NAME] and dry dressing every three days without notifying the physician that the right heel had re-opened. There was no documentation found with a description of the newly opened area, in regards to the size or stage of the open area on the right heel, on 12/3/08. Also, there was no documented evidence that the dressing was pulled back over the heel and monitored daily as ordered. There was no documented evidence that the physician was notified until 6 days later of the open area on the right heel, on 12/9/08, at which time it was described as an open area (no stage), 5 centimeter (cm.) by 1 cm. with large amounts of brown drainage with a very foul odor. The physician ordered a wound culture on that date. The culture showed a heavy growth of Escherichia coli and [MEDICATION NAME] faecalis. Interview with licensed administrative staff "AA" on 4/16/09 at 3:00 p.m. revealed that he/she stated that the physician should have been notified on 12/3/08 when the right heel area had re-opened. | 2014-07-01 |
| 10500 | 10500 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2009-04-16 | 514 | E | 1 | 0 | RX6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized for one (1) resident (#1) from a sample of four (4) residents and other resident's documents ranging from 2008 to 3/25/09, at which time the situation was corrected. Findings include: In the facility's Mortality Review Summary dated 3/25/09 for Resident #1, one of the issues that was documented as a problem during the review, was loose documents found in a drawer in the Nurse's Station (i.e. these items were not filed in the record for review). These items consisted of Medication Administration Records for February 2009 and March 2009, Client Flow Sheets for January 2009 and March 2009, Food and Fluid sheets for February 2009 and March 2009, Vital Sign records for 6/15/08 through 3/01/09, 2008 [MEDICAL CONDITION] Records, some Laboratory Reports that had been seen by the physician, but not filed in the record, Pharmacy/Consultant Notes of 10/29/08 and 9/25/08, Pain Assessments with various dates, Monthly Nursing Review note dated 10/08, One integrated progress note sheet dated 9/25/08 through 10/07/08, Physician's Progress note dated 11/10/08, and Renewal Orders dated 11/10/08. During interview with Administrative Nurse "AA" on 4/16/09 at 3:30 p.m., she stated that during this period of time, there was not a full-time clerk assigned to this unit and thus the filing had not been kept up to standards. At the time of this survey, the above deficiency had been corrected, as the facility had implemented the following: 1. Assigned a clerk to cover this unit to ensure that all filing is kept up to date and in accordance with standards. 2. Administrative Nursing Staff had developed a policy that addressed the practice of recording vital signs in multiple places, as the above method made tre… | 2014-07-01 |
| 10425 | 10425 | PRUITTHEALTH - FORSYTH | 115418 | 521 CABINESS ROAD | FORSYTH | GA | 31029 | 2009-04-29 | 157 | D | 1 | 0 | 5I7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to immediately consult with the physician for one (1) resident (#1), of seven (7) sampled residents, when there was a significant change in the resident's physical status, related to the development of significant bruising while on anticoagulant therapy. Findings include: Record review for resident #1 revealed that the resident was on anticoagulant therapy. Additional review revealed a nursing note of 3/18/09 at 8:30 p.m. which documented that the Certified Nursing Assistant called the Licensed Nurse to the resident's room. The note further documented that the resident was observed with large discoloration, purplish color to the right abdomen and the resident would be monitored for any signs and symptoms of bleeding. A note later on this shift at 10:45 p.m. documented no change in size or color of discoloration. There was no further evidence to indicate any monitoring or assessment of the large discoloration until 3/19/09 at 5:45 a.m. At which time, the Licensed Nurse documented no further discoloration noted to the bruised area on abdomen and right flank, no bleeding out noted and will continue to observe. A nursing note of 3/19/09 at 4:10 p.m., documented resident noted to have large discoloration to the right side of abdomen, generalized yellow color and physician notified. The physician ordered that STAT lab work, consisting of Basic Metabolic Panel (BMP), liver panel and [MEDICATION NAME] time with INR (PT/INR), be done at this time. Thus representing a delay of approximately twenty (20) hours since the initial note of 3/18/09 at 8:30 p.m. which documented the large discoloration of the right abdomen. A nursing note of 3/20/09 at 12:25 a.m. documented that the laboratory work was received. Per review of the laboratory work dated 3/20/09, a Panic Call was made to the nursing home to give the critical abnormal values to the Licensed Practical Nurse. The [MEDICATION NAM… | 2014-07-01 |
| 10498 | 10498 | OAKS HEALTH CTR AT THE MARSHES OF SKIDAWAY ISLAND | 115715 | 95 SKIDAWAY ISLAND PARK ROAD | SAVANNAH | GA | 31411 | 2009-05-06 | 282 | D | 1 | 0 | JSSY11 | Based on observation, record review, and staff interview the facility failed to update the plan of care for pain management and safety devices one resident (#1) on a survey sample of three (3) residents. Findings include: Review of the Significant Change Minimum Data Set (MDS) dated 3/18/09, revealed the resident had sustained a fall in the past 30 days. Furthermore, the resident experienced hip pain on a daily basis that was of moderate intensity. Review of the current plan of care dated 04/22/09 for falls revealed a notation that the resident had a fall and the approach was listed as a chair alarm. However, there was no plan designating when the chair alarm was to be utilized and who was responsible to apply and monitor the chair alarm. Also, a bed alarm is being utilized but was not included on the careplan. Additionally, there was no plan of care for the resident's daily complaints of pain. Interview with the sitter on 05/06/09 at 12:40 p.m., who is present with the resident Monday through Friday from 9:00 a.m. to 3:00 p.m., revealed that the chair alarm is not utilized when she is present during the day. However , when the resident is in bed a bed alarm is utilized. Further interview with the charge nurse, at 12:45 p.m., revealed that the chair alarm is not utilized when the sitter is present, but should be used when someone is not present with the resident. Additionally, the bed alarm is utilized at all times when the resident is in bed. Observation of resident #1 at 11:30 a.m. revealed the resident was sitting up in the wheelchair with the sitter present in the room. There was no chair alarm present. Further observation at 12:40 p.m. revealed a bed alarm was in place. | 2014-07-01 |
| 10476 | 10476 | PRUITTHEALTH - DECATUR | 115647 | 3200 PANTHERSVILLE ROAD | DECATUR | GA | 30034 | 2009-05-13 | 157 | D | 1 | 0 | FLRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility document review, family interview, and staff interview, the facility failed to immediately consult with the physician, and notify the family, of bruising of the right eye and left arm for one (1) resident ("A") in a survey sample of five (5) residents. Findings include: Record review for Resident "A" revealed that the resident had current physician's orders [REDACTED]. A Nurse's Note of 04/28/2009 at 4:30 a.m. documented that the resident was combative and had sustained a skin tear on the top of the left arm during an altercation with a staff member, and that a treatment was applied to the area. A Nurse's Note of 04/28/2009 at 5:00 a.m. documented that the physician was notified of the incident and that the residence of the responsible party was called. In a written statement dated 04/28/2009, Certified Nursing Assistant (CNA) "CC", who was the CNA providing care to the resident at the time of the altercation referenced above, documented the injury to the resident's arm, but further documented that no bruising was noted on the residents' head or face at the time of the incident. In a written statement by CNA "AA", this CNA documented that she had been told during the 7:00 a.m. report that Resident "A" had been combative earlier in the morning, and that when she made rounds and began the provision of morning care, she noticed a nickle-size reddish-purple bruise on the right side of the resident's eye. The facility's Investigative Summary documented that during interview, CNA "AA" had indicated that she then reported her findings to Registered Nurse "DD". In a written statement by Registered Nurse "DD", this nurse documented that upon assessment on 04/28/2009, she had observed a red area on right outer eye area of Resident "A" which then darkened throughout the day. However, further record review revealed no evidence to indicate that the physician was immediately consulted, or the the family was notified, of the… | 2014-07-01 |
| 10629 | 10629 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 203 | D | L1C411 | Based on record review and staff interview, the facility failed to issue a written notice of discharge/transfer at least 30 days before the discharge or transfer for one (1) resident from seventeen (17) sampled residents. Findings includes: Record review for resident #16 revealed a nurse's note dated 4/30/09 that indicated the resident was discharge to another nursing home. Further review revealed a social service note dated 4/20/09 that the social service staff spoke with the resident's son regarding that the resident had been observed smoking in the room and that cigarettes were found in the room. No other written notification related to the resident's discharge was found in the resident's medical record. Interview with Social Worker "AA" on 5/13/09 at 10:10 am revealed that she did not issue a written notice related to discharge of this resident to another nursing home. | 2014-01-01 | ||
| 10630 | 10630 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 322 | D | L1C411 | Based on observations, staff interviews, and review of facility policy, the facility failed to provide appropriate positioning, during incontinence care, for two residents (2) residents (#4, #9) receiving gastrostomy tube feeding from a sample of seventeen (17) residents. Findings include: 1. Observation on 5/13/09 at 8:15 am of CNA "BB" providing incontinence care to resident # 9 revealed that tube feeding was being administered via a pump at 55 cc per hour. During the care the head of the resident's bed was flat and the tube feeding continued to infuse. Interview on 5/13/09 at 8:35 am with CNA "BB" revealed that the she was suppose to keep the head of the bed up during incontinent care or get the nurse to turn the tube feeding off. "BB" acknowledge that the feeding continued to infuse while the resident was flat in bed. 2. Observation on 5/11/09 at 1:30pm. of CNA "BB" providing incontinence care to resident #4, revealed that tube feeding was infusing via pump and she lowered the head of the bed to lower tha thirty (30) degrees. The CNA did not pause or stop the feeding while providing care. Interview on 5/11/09 at 1:35pm with CNA "BB" revealed that she was never instructed to stop or pause the feeding pump when providing care. She further revealed that she never notified the nurse prior to care or lowering the head of the bed. Interview with Director of Nursing (DON) "CC" on 5/11/09 at 3:10pm revealed that she was not aware of a policy to stop or pause the feeding pump when head of the bed is lowered. Review of the facility policy for Tube Feeding indicated that a resident's head will be elevated at least 30-45 degrees at all times with continuous feedings unless temporarily stopped when the head is lowered to render care. | 2014-01-01 | ||
| 10631 | 10631 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 502 | D | L1C411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the February 2009 Pharmacist consultant report and staff interview the facility failed to ensure that a Comprehensive Metabolic Panel was obtained in a timely manner for one (1) resident (#1) from a sample of seventeen (17) residents. Findings include: Review of the medical record for resident #1 revealed a physician's orders [REDACTED]. Further review revealed no laboratory results in the record. Review of the Monthly Pharmacist Reviews dated February 2009 indicated a CMP was due in February and then every 6 months. Interview with Unit Manager "EE" on 5/12/09 at 1:00pm revealed that when laboratory test are ordered there is one drawn at the time of order as a baseline and then as frequent as ordered by the physician. "EE" further revealed the first/base line or any CMP had not been done after the 2/23/09 physician's orders [REDACTED]. | 2014-01-01 | ||
| 10444 | 10444 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2009-05-20 | 309 | D | 1 | 0 | 6BO211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that physicians' orders were followed in regards to sliding scale insulin coverage for three (3) residents (#s 1, 2 and 3) and also for routine insulin administration for one (1) resident (#3) from a survey sample of four (4) residents. Findings include: 1. Record review for Resident #2 revealed a current physician's orders [REDACTED]. [REDACTED]. However, record review for this resident, to include review of the March 2009 medication record, revealed no evidence to indicate that the resident had been administered any [MEDICATION NAME] R insulin for the 03/10/2009, 6:00 a.m. blood sugar of 171. Also, review of the March 2009 medication record revealed that 2 units of [MEDICATION NAME] R was administered in error to this resident for the 03/18/2009, 4:00 p.m. blood sugar of 136. No insulin should have been administered for this blood sugar level, per the physician's sliding scale insulin order. During an interview conducted on 05/20/2009 at 5:55 p.m., the Director of Nursing (DON)acknowledged the above. 2. Record review for Resident #3 revealed current physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. However, further record review for this resident, to include review of the March 2009 medication record, revealed no evidence to indicate that the routine dose of 30 units of [MEDICATION NAME] was administered on 03/10/2009 at 6:00 a.m., or that the resident had been administered any sliding scale [MEDICATION NAME] R for the 03/10/2009, 6:00 a.m. blood sugar level of 166. Additional record review for this resident, to include review of the May 2009 medication record, revealed no evidence to indicate that the resident received any sliding scale insulin coverage of [MEDICATION NAME] R as ordered at 8:00 p.m. on 05/03/2009 for a blood sugar level of 273. During an interview conducted on 05/20/2009 at 5:55 p.m., the DON acknowledged the above… | 2014-07-01 |
| 10413 | 10413 | CEDAR SPRINGS HEALTH AND REHAB | 115381 | 148 CASON ROAD | CEDARTOWN | GA | 30125 | 2009-06-03 | 365 | K | 1 | 0 | 80UN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital document review, and staff interview, the facility failed to provide food prepared in a form to meet the individual needs of one (1) resident (#1), of a total of five (5) residents on the survey sample who had been assessed to need, and ordered to receive, pureed food, on the total survey sample of twelve (12) residents. A total of fifteen (15) residents (including Residents #1, #3, #8, #9 and #10 on the survey sample) required pureed diets. This resulted in serious harm to Resident #1, who was subsequently diagnosed with [REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed from May 17, 2009 through June 3, 2009, at which time the facility took action to abate the immediate jeopardy. Findings include: Record review for Resident #1 revealed a speech therapy Progress Note of 06/06/2008 which indicated that the resident had been receiving skilled speech therapy and could safely swallow a pureed diet. A 05/09/2008 Telephone Order specified that the resident receive a thin puree diet. Further record review revealed a May 2009 physician's orders [REDACTED]. A Nurse's Note of 05/17/2009 at 9:20 a.m. documented that a certified nursing assistant (CNA) had summoned Nurse "AA" to the South Wing where this nurse observed Resident #1 lying on the floor, and observed another nurse administering the [MEDICATION NAME] Maneuver and a CNA doing mouth sweeps. Nurse "AA" documented that she noted the resident's breathing to be shallow and went to get a Rescue Bag. Nurse "AA" documented that upon returning, she took over administering the [MEDICATION NAME] Maneuver and the other nurse took over doing mouth sweeps. This Note documented that Emergency Medical Technicians then arrived and took over the resident's care, and that the physician was notified. A Nurse's Note of 05/17/2009 at 12:00 p.m. documented that the resident had been transferred to the hospital. A 05/17/… | 2014-07-01 |
| 10448 | 10448 | PRESBYTERIAN HOME, QUITMAN, IN | 115498 | 1901 WEST SCREVEN STREET | QUITMAN | GA | 31643 | 2009-06-03 | 323 | G | 1 | 0 | 1V5Y11 | Based on record review, staff interview, and hospital document review, it was determined that the facility failed to ensure that adequate supervision was provided to prevent injury during a chair-to-bed transfer for one (1) resident (#1) from a survey sample of five (5) residents. This failure resulted in harm by causing a large laceration on the right lower leg of Resident #1. Findings include: Record review for Resident #1 revealed that a new intervention had been added to his/her plan of care to prevent falls on 03/05/2009. This intervention specified for the resident to be transferred with the assistance of two persons. According to the 05/21/2009, 1:45 p.m. nursing notes, the resident was being assisted to bed from the wheelchair by only one (1) certified nursing assistant (CNA). During the transfer, the resident exhibited agitation as he/she was being transferred to the bed from the wheelchair. When the resident had been put to bed, the CNA noted blood on the resident's right pant's leg and immediately reported this to the charge nurse. The charge nurse went to check the resident's right lower leg and found a large laceration to the back of the right leg. The nurse documented that the laceration extended from the mid-calf of the outer leg down to the ankle area. The Unit Manager for this unit and the Director of Nursing (DON) were immediately notified of the area of laceration on the resident's right lower leg. The wound was cleaned with normal saline, and Steri-Strips and a pressure bandage were applied. Documentation indicated that the physician and the family were immediately notified, and that the resident was immediately transferred to the hospital for repair of the laceration. Hospital documentation indicated that the hospital physician described the wounded area as a 30 centimeter (cm.) to 35 cm. curved laceration, down to the fascia. During interviews with the DON and Administrator conducted on 06/02/2009 at 4:30 p.m., these staff members both acknowledged that the above incident had occurred on 05/… | 2014-07-01 |
| 10449 | 10449 | PRESBYTERIAN HOME, QUITMAN, IN | 115498 | 1901 WEST SCREVEN STREET | QUITMAN | GA | 31643 | 2009-06-03 | 282 | G | 1 | 0 | 1V5Y11 | Based on record review, staff interview, and hospital document review, it was determined that the facility failed to ensure that adequate supervision was provided to prevent injury during a wheelchair-to-bed transfer for one (1) resident (#1) from a survey sample of five (5) residents. This failure resulted in harm by causing a large laceration on the right lower leg of Resident #1. Findings include: Record review for Resident #1 revealed a 03/05/2009 intervention on the plan of care to prevent falls which specified for the resident to be transferred with the assistance of two (2) persons. However, a 05/21/2009, 1:45 p.m. nursing note documented that the resident was assisted to bed from the wheelchair by only one (1) certified nursing assistant (CNA). When the resident had been put to bed, the CNA noted blood on the resident's right pants' leg. The CNA notified the charge nurse, who assessed the resident's right lower leg and documented a large laceration to the back of the leg which extended from the mid-calf of the outer leg down to the ankle area. Documentation indicated that the physician was immediately notified and that the resident was immediately transferred to the hospital. Hospital documentation indicated that the hospital physician described the wounded area as a 30 centimeter (cm.) to 35 cm. curved laceration, down to the fascia. During interviews with the DON and Administrator conducted on 06/02/2009 at 4:30 p.m., these staff members both acknowledged that the laceration on the resident's right lower leg had occurred during the 05/21/2009 transfer when the CNA had failed to use a two-person transfer, per the resident's plan of care. Cross refer to F323 for more information regarding Resident #1. | 2014-07-01 |
| 10645 | 10645 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 225 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview the facility failed to ensure that an injury of unknown origin was investigated and immediately reported to the State Survey and Certification Agency for one (1) resident ("A") on a sample of thirty (30) residents. The findings include: Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed that resident "A" complained of chest pain since 5/21/09 and had received an antacid and pain medication without relief. The physician was notified and orders were obtained to send the resident to the hospital emergency room for evaluation. Review of a Nurse's Note dated 5/23/09 at 2:15 a.m. revealed the resident returned from the hospital with a [DIAGNOSES REDACTED]. The 24 Hour Report/Change of Condition Report dated 5/22/09 included a notation that the resident had returned to the facility at 2:00 a.m. with a fractured right rib. Interview with the Licensed Practical Nurse Unit Manager (LPN) "EE" on 6/15/09 at 2:05 p.m. revealed she was unaware that the resident had a fractured rib and would obtain the report from the hospital. Review of the Radiologist Report with an order date of 5/22/09 documented there was a subacute [MEDICAL CONDITION] posterior 12th rib. Review of the Minimal Data Set assessment revealed resident "A" had short term memory loss, however interview with the resident on 6/15/09 at 11:30 a.m. revealed the resident was able to state place of residence, day of the week, month and year of admission, and family information. During interview with the resident on 6/15/09 at 3:10 p.m. he/she remember having severe pain in the chest area and he/she was told of the rib fracture a few days ago but could not remember which day. Interview with the Director of Nurses (DON) on 6/16/09 at 7:22 a.m. revealed she was unaware that the resident had a fractured rib and therefore it had not been been investigated or reported to the State Agency. Further interview with the DON on 6/16/09 at 9:30 a.m.… | 2014-01-01 | ||
| 10646 | 10646 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 431 | B | 5ICH11 | Based on staff interview, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs. The findings include: During an interview with the Director of Nurses, on 6/17/09 at 7:45 a.m., she stated that the facility did not have any system of reconciliation of controlled drugs and the facility relied on proof of use sheets utilized during shift to shift controlled drug counts done by staff nurses. | 2014-01-01 | ||
| 10647 | 10647 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 309 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's orders for blood glucose monitoring for one (1) resident (#7) and follow up appointments after an injury for one (1) resident (#13) and on a sample of thirty (30) residents. The findings include: 1. Record review revealed resident #7 to have a [DIAGNOSES REDACTED]. In addition to the routine insulin, the resident was to receive additional insulin as needed based on blood glucose monitoring at 6:30 a.m. and 4:30 p.m. Physician orders included to notify the physician for blood glucose values greater than 400. Review of the facility policy [MEDICAL CONDITION] (elevated blood glucose), the clinical record should have included the resident's symptoms, blood sugar results, the resident's oral intake, notification of the physician and family, and the resident's response to treatment. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse "EE" on 6/16/09 at 12:30 p.m. confirmed that the physician was not made aware of this elevated blood sugar. Interview on 6/16/09 at 4:00 p.m. with the Director of Nursing revealed the nurse should have documented the blood sugar, the resident's symptoms and that the physician was notified. 2. Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed resident #13 returned to the facility from the emergency room with a [DIAGNOSES REDACTED]. There was no documentation that the resident had a follow up physician visit after this injury. Interview with the Assistant Director of Nurses on 6/17/09 at 8:20 a.m. confirmed that a follow up physician visit had not been conducted. | 2014-01-01 | ||
| 10648 | 10648 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 371 | F | 5ICH11 | Based on observation, record review and staff interview the facility failed to store and prepare food under sanitary conditions for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed: The microwave was soiled inside with food particles on all sides, particularly the top and bottom. A pan of pureed bread was sitting on top of the stove ledge. The Food Service Director (FSD) confirmed it was for the lunch meal and should be refrigerated or held at 135 degrees Fahrenheit (F). In the dishmachine area the tile floor was wet and soapy. The FSD stated staff washed the floor a few times each day and used a hose with a sprayer attachment. Observation revealed the water from the floor was being sprayed onto clean dished that were stacked on carts. The can opener in the food preparation area had a thick, dark gummy substance built up on the blade. The microwave in the dining room was dirty on all six (6) sides. Observation on 6/16/09 at 7:05 a.m. revealed: Three (3) items in the cooler did not register a temperature of 41 degrees F or less. The facility thermometer was calibrated twice to ensure accuracy. Pork chops were 47 degrees, black eyed peas were 49 and buttermilk was 48 degrees F. These items were in the cooler over eighteen (18) hours. The tile floor throughout the kitchen needed repair including grout cleaning and replacement. Interview with the Administrator and Maintenance Director on 6/17/09 at 9:00 a.m. revealed they were aware of the tile problems but did not have a specific plan for repairs at this time. Review of the Daily Cleaning Assignments for kitchen staff provided by the facility and signed by staff for 5/11/09 to 6/07/09 revealed cleaning the microwave was not listed under any assignments. | 2014-01-01 | ||
| 10649 | 10649 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 364 | E | 5ICH11 | Based on observation, resident and staff interview the facility failed to serve food using methods that conserve the nutritional value for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed ground pork chops, gravy, potatoes and rutabagas were being held hot on trayline. Interview with the Food Service Director (FSD) at that time revealed staff were served at 11:00 a.m. and residents were served at noon. Observation on 6/16/09 at 7:30 a.m. revealed a large pan of green beans boiling on the stove. The FSD stated the beans were for lunch at noon. At 9:55 a.m. the trayline held chicken stew, mashed potatoes, gravy and beef steak also for lunch. Interview with resident "H" on 6/16/09 at 3:00 p.m. revealed the green beans were always over cooked. | 2014-01-01 | ||
| 10650 | 10650 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 253 | B | 5ICH11 | Based on observation and staff interview the facility failed to provide housekeeping services to maintain a sanitary and comfortable interior related to dirty floors and furniture in need of repair on two (2) of three (3) Wings (East and West) and one (1) of two (2) solariums. The findings include: During intial tour of the East Wing on 6/15/09 at 11:30 a.m. the floors of the hallways were observed to be dirty with a black substance waxed into the tile floor. General observation tour on 6/16/2009 at 9:30 a.m. revealed that the three (3) hallways that make-up the East Wing of the building were in need of stripping and rewaxing. Additional observations at that time: Room 204- The door frame to the bathroom was scuffed and missing paint. The inside of the bathroom door was scuffed and the paint was peeling in a one (1) foot by eight (8) inch section. Room 236- The bedside table for the resident in the second bed was marred and scraped and had missing veneer across the entire front and at the bottom corners. Room 247- The floor was marred with the wax scraped as if someone had pulled something heavy across the floor. Interview with the Administrator on 6/16/2009 at 3:15 p.m. revealed that she was aware the hallways were in need of stripping and waxing. Observation on the West wing on 6/16/09 at 7:25 a.m. revealed the following: Room 302 - Bed A nightstand was missing the trim strip around the top of the stand. Room 326 - The foot board was missing the side strips, exposing bare wood or fiber board. Room 335 - Bed A footboard was scuffed on the edges and was missing the finish. Room 337 - A water stain was on the wall to the right of the air conditioner and was visible from the hallway. One of two (1 of 2) solariums had peeling wallpaper at the air conditioner and window sill. The pink sofa's vinyl was darkened in spots making the sofa appear dirty. One of two (1 of 2) green benches in the hallway had vinyl that had was discolored. Interview on 6/16/09 at 2:00 p.m. with the Maintenance and Housekeeping Supervisors con… | 2014-01-01 | ||
| 10651 | 10651 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 363 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide fruit juice as planned on the menu for breakfast for one (1) resident, resident "D" on a sample of thirty (30) residents. The findings include: Review of the physician orders [REDACTED]. Review of the prepared and planned menu for 6/16/2009 revealed that the resident should have received four (4) ounces of a juice with breakfast. Observation of the resident on 6/16/2009 at 7:50 a.m. revealed that the resident received the pureed food as ordered but not the juice as indicated on the meal plan. The resident told the surveyor that they liked juice. Observation of the resident on 6/17/2009 at 7:40 a.m. revealed that the resident did not receive any juice for breakfast. Interview with Certified Nursing Assistant (CNA) "BB" at that time revealed she did not know why the resident had not received juice. It was observed that other residents in the dining room did receive juice with their breakfast. Review of the resident's diet card did not list juice as a dislike. | 2014-01-01 | ||
| 10652 | 10652 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 372 | C | 5ICH11 | Based on observation and staff interview, the facility failed to ensure refuse containers were in good condition for the garbage compactor. The findings include: Observation on 6/15/09 at 11:45 a.m. revealed the garbage compactor to be dripping a dark liquid from the roller end. The liquid was sufficient in quantity to cause a oily, milky runoff three (3) feet wide by sixteen (16) feet long. Interview on 6/15/09 at 3:35 p.m. with the Maintenance Director confirmed that the compactor was leaking and needed repair. | 2014-01-01 | ||
| 10469 | 10469 | WESTWOOD NURSING CENTER | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2009-07-07 | 279 | D | 1 | 0 | XBED11 | Based on observation, record review, and staff interview, the facility failed to appropriately update the care plan, regarding supervision during smoking, for one (1) resident (#2) on a survey sample of seven (7) residents. Findings include: Record review for Resident #2 revealed a 04/08/2009 Care Plan entry which indicated that the resident was a smoker and required supervised smoking. However, a Safe Smoking Evaluation dated 06/15/2009 for Resident #2 assessed the resident to be capable of smoking independently, or with set-up, and unsupervised. During an interview with the Director of Nursing (DON) conducted on 07/07/2009 at 1:38 p.m., the DON acknowledged that the resident had been assessed as being a safe smoker in June 2009 and that the resident's Care Plan was to be revised to reflect the smoking assessment. Observation of the smoking porch conducted on 07/07/2009 from 9:50 a.m. until 10:10 a.m. revealed the resident smoking without staff supervision. | 2014-07-01 |
| 10470 | 10470 | WESTWOOD NURSING CENTER | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2009-07-07 | 514 | E | 1 | 0 | XBED11 | Based on observation, record review, resident interview, and staff interview, the facility failed to consistently document that bathing and activities of daily living were completed for four (4) residents ("A", "B", "C" and "D") of seven (7) sampled residents. Findings include: 1. Review of the June 2009 Verification of Daily Resident Care sheet (the documented purpose of which was for Certified Nursing Assistants to document resident care and observation of residents as indicated in resident Care Plans) for Resident "A" revealed no Certified Nursing Assistant (CNA) signatures to indicate that resident observation and care had been provided for the 7:00 a.m.-3:00 p.m. shifts on 06/01/2009, 06/29/2009, and 06/30/2009; for the 3:00 p.m.-11:00 p.m. shifts on 06/13/2009, 06/17/2009, 06/18/2009, and 06/20/2009; and for the 11:00 p.m.-7:00 a.m. shifts on 06/09/2009, 06/21/2009, 06/29/2009, and 06/30/2009. During an observation of Resident "A" conducted at 1:05 p.m. on 07/07/2009, the resident was observed to be neat and clean. During an interview conducted at the time of this observation, the resident stated that staff did provide routine grooming. 2. Review of the July 2009 Verification of Daily Resident Care sheet for Resident "B" revealed no CNA signatures to indicate that resident observation and care had been provided for the 7:00 a.m.-3:00 p.m. shift of 07/06/2009; for the 3:00 p.m.-11:00 p.m. shifts of 07/05/2009 and 07/06/2009; and for the 11:00 p.m.-7:00 a.m. shifts of 07/02/2009, 07/03/2009, and 07/05/2009. During an observation of Resident "B" conducted on 07/07/2009 at 10:10 a.m., the resident was observed to be neat and clean. During an interview conducted at the time of this observation, the resident stated that staff did provide routine bathing and grooming. 3. Review of the July 2009 Verification of Daily Resident Care sheet for Resident "C" revealed no CNA signatures to indicate that resident observation and care had been provided for the 7:00 a.m.-3:00 p.m. shifts of 07/04/2009, 07/05/2009, and 07/06/… | 2014-07-01 |
| 10400 | 10400 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-07-14 | 203 | E | 1 | 0 | 04R611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, it was determined that the facility failed to notify the resident, and a family member or legal representative, of hospital transfer in writing either before, at the time of, or since the transfer for four (4) residents ("A", #2, #3 and #4) in a survey sample of four (4) residents. Findings include: 1. Record review for Resident "A" revealed a Nurse's Note of 06/11/2009 which documented that the resident was transferred to the hospital. However, further record review revealed no evidence to indicate that either before, at the time of, or since this hospital transfer, the resident and the resident's family had received a written transfer notice indicating the reason for the transfer, the effective date of the transfer, the location to which the resident was being transferred, a statement that the resident had the right to appeal the transfer, and the ombudsman's name, address and telephone number. During an interview with the family of Resident "A" on conducted on 07/14/2009, the family member stated that no written transfer notice had been provided when the resident was transferred to the hospital. 2. Record review for Resident #2 revealed a Nurse's Note which documented that Resident #2 was transferred to the hospital on [DATE]. There was, however, no evidence to indicate that either before, at the time of, or since this hospital transfer, the resident and the resident's family had received a written transfer notice indicating the reason for the transfer, the effective date of the transfer, the location to which the resident was being transferred, a statement that the resident had the right to appeal the transfer, and the ombudsman's name, address and telephone number. 3. Record review for Resident #3 revealed a Nurse's Note which documented that the resident was transferred to the hospital on [DATE] at 11:45 a.m. There was, however, no evidence to indicate that either before, at… | 2014-07-01 |
| 10401 | 10401 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-07-14 | 205 | E | 1 | 0 | 04R611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, it was determined that the facility failed to provide written information to the resident, and family member or legal representative, either at the time of, or since, hospital transfer, that specified the duration of the bed-hold policy for four (4) residents ("A", #2, #3 and #4) in a survey sample of four (4) residents. Findings include: 1. Record review for Resident "A" revealed a Nurse's Note of 06/11/2009 which documented that the resident was transferred to the hospital. There was, however, no evidence to indicate that either at the time of, or since, this hospital transfer, the resident and the resident's family had received written information regarding the duration of the facility's bed-hold policy. During interview with the family member of Resident "A" conducted on 07/14/2009 at 11:00 a.m., it was stated that no written notification specifying the duration of the bed hold policy was provided at the time of resident's transfer to the hospital. 2. Record review for Resident #2 revealed a Nurse's Note which documented that Resident #2 was transferred to the hospital on [DATE]. There was, however, no evidence to indicate that either at the time of, or since, this hospital transfer, the resident and the resident's family had received written information regarding the duration of the facility's bed-hold policy. 3. Record review for Resident #3 revealed a Nurse's Note which documented that the resident was transferred to the hospital on [DATE] at 11:55 a.m. There was, however, no evidence to indicate that either at the time of, or since, this hospital transfer, the resident and the resident's family had received written information regarding the duration of the facility's bed-hold policy. 4. Record review for Resident #4 revealed a Nurse's Note which documented that the resident was transferred to the hospital on [DATE]. There was, however, no evidence to indicate that either a… | 2014-07-01 |
| 10555 | 10555 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 371 | E | LY2811 | Based on observations , staff interviews, and the facility inservice records, the facility failed to ensure that dietary staff wore the proper facial hair restraint. Findings include: Observation on 7/20/09 at 1:00 pm and 1:45 pm, revealed a male dietary staff walking around in the kitchen area with the beard restraint hanging around his neck, under his chin. He was observed standing over food near the serving line area, talking to staff. During an interview with Dietary Staff "CC" on 7/20/09 at 1:47 pm, it was revealed that the dietary male staff should had been wearing a hair restraint.. Interview on 7/20/09 at 2:50 pm with the Registered Dietian "DD" revealed that the dietary staff should be wearing beard restraints over facial areas. A review of the Dietary Monthly Inservice Record held on 5/26/09 revealed that all hair must be covered including beard and mustaches with hair restraints. Further review revealed documented evidence that the dietary staff member had attended this particular inservice. | 2014-04-01 | ||
| 10556 | 10556 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 315 | D | LY2811 | Based on a review of the Resident Census and Condition report, facility's policy/procedure for Bladder Retraining, Bowel and Bladder Elimination Pattern Assessment tool, resident and staff interviews, the facility failed to restore/maintain as much normal bladder function for one (1) resident ( "Y" ) from a sample of twenty four (24) residents. Findings include: During an interview with resident "Y" on 7/21/09 at 10:30 am, revealed that she was continent during the day but uses a brief at night. She further revealed that she occasionally has accidents if she does not get to the toilet fast enough. She indicated that the Certified Nursing Assistants ( CNAs) check and change her when she wears the briefs at night. During a review of the admission MDS ( Minimum Data Set ) assessment for resident "Y" dated 8/20/08, and quarterly assessments dated 1/16/09 and 7/1/09 revealed the resident was assessed as being continent of bladder but required extensive assistance with transfers. Record review revealed a Bladder Elimination Assessment form dated 3/7/08 through 3/13/08, which was to determine the resident's bladder function/toileting schedule, was incomplete. A review of the facility policy/procedure for Bladder Independence/Retraining that was in effect since 11/03 revealed the following criteria: Assess the resident for factors that would create difficulty for the resident to toilet safely. Establish interventions to meet individual resident's goals. Maintain a voiding schedule that is based on the resident's voiding assessment Further record review revealed the facility had failed to follow their policy/procedure to assess/maintain this residents' bladder function. Interview with the Director of Nursing (DON) on 7/22/09 at 11:15am revealed that the facility had continued to use a three (3) day voiding and bowel assessment for residents on admission. She further revealed that the last assessment for a resident for a bowel and bladder program was October 2008. There are no residents currently on a Bowel and Bladder Ret… | 2014-04-01 | ||
| 10557 | 10557 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 356 | B | LY2811 | Based on observations and review of the facility posted staffing data forms, the facility failed to post the daily census for three (3) days of the survey (7/20/09 through 7/22/09). Findings include: Observations of the staffing data forms posted on 7/20/09 through 7/22/09, at 1:00pm each day, revealed no resident census posted on the staffing data form. | 2014-04-01 | ||
| 10558 | 10558 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 469 | D | LY2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to ensure that one (1) resident ( "Z" ) from a sample of twenty-four (24) residents was free of pests. Findings include: Observation on 7/22/09 at 8:15 am revealed tiny insects crawling on resident "Z's " right hand and lower part of arm. Further observation revealed tiny insects crawling on the resident's bed on the right side rail and on the call light. Further observation at 8:30 am revealed tiny insects crawling on a bottle of baby powder on the bedside table near the resident's bed and the insects were crawling on the call light cord from the wall to the bed. During an interview with charge nurse "EE" on 7/20/09 at 8:30 am, revealed that the tiny insects were ants and that the ants were also on the bedside table. During an interview with resident "Z" on 7/20/09 at 9:00 am revealed that the resident had problems with ants before in the past, but has never been bitten. She further indicated that she has never had ants on her or in her bed before. Interview with maintenance staff "GG" on 7/22/09 at 9:35 am revealed that there had been no problens in this room with ants, however; ants had been a problem in resident room 128 in the past. A review of the pest management invoice dated 7/15/09 revealed resident room 128 was treated for [REDACTED]. Further interview with maintenance staff "GG" on 7/22/09 at 3:15 pm revealed that the Pest Control Company had determined that the ants in resident's "Z" room were coming in from the outside due to a crack in the wall near the air conditioner unit. | 2014-04-01 | ||
| 10450 | 10450 | GRANDVIEW HEALTH CARE CENTER | 115502 | 618 GENNETT DRIVE | JASPER | GA | 30143 | 2009-07-30 | 333 | D | 1 | 0 | 89QE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, pharmacist, and family interviews, the facility failed to ensure that [MEDICATION NAME] was administered according to physician's orders [REDACTED].#2) from a sample of four (4) residents. Findings include: Record review revealed that resident "C" was readmitted to the facility on [DATE] at approximately 7:30pm with readmission physician's orders [REDACTED]. The resident was also to be admitted to hospice services. The hospice nurse wrote an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview with an Licensed Practical Nurse (LPN)"AA" on 7/30/09 at 1:20pm revealed that the hospice nurse went to Jasper Drugs to fill the [MEDICATION NAME] order. She returned with a bottle labeled [MEDICATION NAME] ( [MEDICATION NAME]) 125 mg in five (5) ml of suspension, administer thirty two (32) ml (800 mg) every eight hours via tube. Interview with a pharmacist at Jasper Drugs on 7/30/09 at 2:05pm and again at 2:35pm revealed that the pharmacist who filled the [MEDICATION NAME] did question the hospice nurse about the dosage, and she assured him that the dosage was correct. This pharmacist further revealed that the normal procedure would have been to check with the physician if in doubt about any medication. Since hospice patients often take larger doses of medication the pharmacist trusted the hospice nurse and filled the [MEDICATION NAME]. Interview with the family member of resident "C" on 7/30/09 at 2:25pm revealed she had become concerned when the resident began sleeping more and not opening his eyes. She indicated that she noted this change on Saturday afternoon 7/18/09. On 7/19/09 this family member approached the facility nurse with her concerns and requested that the resident's medications be reviewed. When she noted that [MEDICATION NAME] 800mg was being given she became alarmed. The resident had never taken more than 100mg twice (bid) or three (tid) times per day depending on la… | 2014-07-01 |
| 10451 | 10451 | GRANDVIEW HEALTH CARE CENTER | 115502 | 618 GENNETT DRIVE | JASPER | GA | 30143 | 2009-07-30 | 514 | D | 1 | 0 | 89QE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of physician orders, the Medication Administration Record [REDACTED]. Findings include: Resident #2 was readmitted to the facility on [DATE] with a physician's orders [REDACTED]. The resident was admitted to a hospice services on 7/18/09. The hospice nurse wrote for [MEDICATION NAME] (800mg) thirty two (32) milliliters (ml) to be given every eight hours via the feeding tube. The [MEDICATION NAME] was transcribed by the facility nurse to the resident's MAR, and the resident received [MEDICATION NAME] 32ml (800mg) three (3) times ( 7/18/09 @ 4:00pm, 12:00 midnight, and 7/19/09 @ 7:00am). The [MEDICATION NAME] written by the hospice nurse had not been reviewed or signed by a physician. Interview with the Director of Patient Care for the hospice service on 7/30/09 at 4:20pm revealed that the hospice nurse was not available for interview. However, she, the director, had spoken to the nurse and she was not sure how this error occurred. The hospice nurse was copying the readmission physician's orders [REDACTED]. The hospice nurse copied the wrong dose of [MEDICATION NAME] and she left a copy with the incorrect dosage on the chart and the facility nurse used that copy. Interview with the LPN "FF" on 7/30/09 at 4:50pm revealed that she had questioned the [MEDICATION NAME] dosage but did not call the hospice nurse or the physician. Interview with the LPN "GG" on 7/31/09 at 5:08 pm revealed she did not question the dosage of the [MEDICATION NAME] when transcribing the medication to the MAR. She further revealed that she not refer to the original readmission orders [REDACTED]. | 2014-07-01 |
| 10438 | 10438 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2009-08-03 | 323 | G | 1 | 0 | LE4211 | Based on record review and staff interview, the facility failed to provided adequate supervision related to fall prevention, per the Care Plan, for one (1) resident (#1) from a survey sample of five (5) residents. The resident subsequently experienced a fall which resulted in a hematoma to the forehead, edema to the nose and the area beneath the nose, and a laceration requiring stitches. Findings include: Record review for Resident # 1 revealed an entry on the Admission Care Plan Record which identified that the resident was at risk for falls, and included as Approaches to address this problem that a Sensor pad was to be provided as ordered, and that staff had been educated that alarms were to be on at all times and activated. A Nurse's Note dated 06/11/2009 at 6:00 p.m. documented that the nurse entered the resident's room and observed the resident face down on the floor with a moderate amount of blood around the head. This Note documented that upon assessment, a small laceration was noted above the right eye, a hematoma was noted to the forehead, and edema was noted to the bridge of the nose and to the area under the nose. This Note documented that Emergency Medical Services 911 was activated and transported the resident to the hospital emergency room . This Note further documented that at the time of the resident's fall, the Sensor pad was in place, but was not activated. A Nurse's Note of 06/11/2009 at 10:45 p.m. documented that the resident had returned to the facility, having received sutures to the forehead. During interview with Administrative Staff "AA" conducted at 11:30 a.m. on 08/03/2009, this staff member acknowledged the incident. This staff member also stated that after the incident, the nurse had inserviced some, but not all, certified nursing assistant staff about the incident and the importance of keeping alarms turned on. | 2014-07-01 |
| 10439 | 10439 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2009-08-03 | 282 | G | 1 | 0 | LE4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to provided care related to fall prevention, per the Care Plan, for one (1) resident (#1) from a survey sample of five (5) residents. The resident subsequently experienced a fall which resulted in a hematoma to the forehead, [MEDICAL CONDITION] to the nose and the area beneath the nose, and a laceration requiring stitches. Findings include: Record review for Resident # 1 revealed an entry on the Admission Care Plan Record which identified that the resident was at risk for falls, and included as Approaches that a Sensor pad was to be provided as ordered, and that staff had been educated that alarms were to be on at all times and activated. A Nurse's Note dated 06/11/2009 at 6:00 p.m. documented that the resident was observed in the room, face down on the floor, with a small laceration above the right eye, a hematoma to the forehead, and [MEDICAL CONDITION] to the bridge of the nose and to the area under the nose. This Note further documented that at the time of the resident's fall, the Sensor pad was in place, but was not activated. A Nurse's Note of 06/11/2009 at 10:45 p.m. documented that the resident had received sutures to the forehead. Refer to F323 for more information regarding Resident # 1. | 2014-07-01 |
| 10471 | 10471 | BAPTIST VILLAGE, INC. | 115615 | 2650 CARSWELL AVE | WAYCROSS | GA | 31502 | 2009-08-03 | 225 | D | 1 | 0 | 0HJT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to report an injury of unknown origin and send the findings of their investigation to the State Survey and Certification Agency for one (1) resident, Resident #1, on a survey sample of five (5) residents. Findings include: Record review for resident #1 revealed a Departmental Note dated 7/20/09 at 9:52 a.m., that documented right leg pain. Medications were administered and the physician was notified with resulting orders to monitor the resident. At 3:12 p.m. the resident continued to complain of right leg pain from the thigh down. The family elected to have the resident evaluated in the emergency room due to a history of blood clots in that extremity. The physician was notified and the resident was transported to the hospital for evaluation. The resident was subsequently admitted with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON), on 8/3/09 at 3:00 p.m., revealed that an investigation was conducted of the incident once it was reported to the facility by the family member after the emergency room surmised the resident had a fall. The cause of the injury was of unknown origin, thus requiring the incident to be report to the State Survey Agency. However the facility did not report the injury of unknown origin to the State Survey and Certification Agency, as required. | 2014-07-01 |
| 10564 | 10564 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 371 | F | DOSV11 | Based on observations, record review and staff interview the facility failed to prepare food under sanitary conditions for all residents consuming food (facility census 89.) The findings include: Observation of the kitchen on 08/03/09 at 9:00 a.m. revealed the can opener blade contained a thick build-up of a dark, sticky substance. Review of the Daily and Weekly Cleaning Assignments revealed that washing and sanitizing of the can opener blade was not listed. Observation on 08/04/09 at 10:50 a.m. revealed multiple raw chicken pieces in a preparation sink under cold, running water. The water was running over the raw chicken and draining down the sink. Interview with a dietary staff member "AA" at this time revealed she did not know that raw meat must also be submerged in water for proper thawing by this method. Interview with the dietary manager on 8/4/09 at 2:35 p.m. revealed she also was not aware this requirement. | 2014-04-01 | ||
| 10565 | 10565 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 323 | D | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to ensure that an intervention, clip alarm, to prevent falls was implemented for one (1) resident (#1) from a sample of twenty one (21) residents. The findings include: Observations of resident #1 conducted 08/03/09 at 10:55 a.m. and 12:50 p.m. revealed the resident had no clip alarm on the bed. Further observation on 08/04/09 at 7:55 a.m. revealed there was no alarm on the bed. A second observation on 8/04/09 at 10:30 a.m. revealed the resident was in bed and no clip alarm was on. Interview with Licensed Practical Nurse ( LPN) "BB" on 8/4/09 at 11:00 a.m. revealed an clip alarm was located and applied to the resident. Review of the clinical record for resident #1 revealed he was admitted [DATE]. Review of Nurse's Notes revealed he had three (3) falls since admission. These falls occurred on 06/13/09, 07/25/09 and 07/27/09 and were a results of the resident attempting to toilet himself. Following the 07/27/09 fall, the facility added an intervention of a bed clip alarm. Review of the care plan for resident #1 revealed he was care planned for the risk for falls on 05/09/09. On 7/27/09 the care plan was updated to include a clip alarm to bed. | 2014-04-01 | ||
| 10566 | 10566 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 365 | D | DOSV11 | Based on observation, record review and staff interview the facility failed to provide the correct consistency diet to meet the needs of one (1) resident (#1) from a sample of twenty one (21) residents. The findings include: Review of the clinical record for resident #1 revealed that on June 24, 2009 the resident's diet was changed to mechanical soft. On June 25, 2009 this diet order was clarified to a Liberalized Diabetic, Mechanical Soft with nectar thick liquids. Observation of the resident's meal on 08/03/09 at 12:50 p.m. revealed the resident received a pureed diet with nectar thick liquids. Observation of the breakfast meal on 08/04/09 at 7:45 a.m. revealed the resident received a pureed diet with nectar thick liquids again. Interview with the Dietary Manager on 08/04/09 at 7:50 a.m. revealed the dietary department did not receive the diet change from the nursing department. | 2014-04-01 | ||
| 10567 | 10567 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 520 | E | DOSV11 | Based on staff interviews and review of facility quality assurance records, the facility failed to ensure that the performance improvement plan for missing physician's progress notes was effective for ten (10) residents (#3, #4, #6, #7, #8, #9, #10, #15, #16, and #20) from a sample of twenty-one (21) residents. Findings include: Record reviews for residents #3,#4, #6, #7, #8, #9, #10, #15, #16, and #20 revealed missing physician's progress notes. Interview on 8/4/09 at 3:40 pm with the physician revealed that there has been a problem with progress notes missing from resident's medical records. She further indicated that she has had problems with missing progress notes since October 2008. Interview of 8/5/09 at 9:45 am with the Director of Health Services revealed that the physician's progress notes were missing from resident's medical records. Review of the quality assurance improvement action plan revealed that the facility identified the problem with missing progress notes in February 2009. The plan revealed that physician's progress notes were discussed in the 3/20/09 and 6/29/09 meetings. Each meeting indicated that notes were still missing from medical records. There was no evidence that the approaches developed to resolve the missing progress notes have been effective. According to the plan the last approach was to involve corporate, with a target date of 8/30/09. | 2014-04-01 | ||
| 10568 | 10568 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 226 | D | DOSV11 | Based on staff interviews, review of facility policy and records, the facility failed to ensure that two (2) Certified Nurses Assistants (CNA) of five (5) CNAs interviewed had received training on abuse prohibition. Findings include: Review of the facility's Abuse Policy for staff training indicated that training on abuse will be done during initial orientation for all new staff and volunteers. This will include oriented to the facility policy related to abuse prohibition including what constitutes abuse, what to do if they hear or see abuse, and the appropriate interventions to deal with aggressive and/or catatropic reactions of residents/patients,including burnout, stress management and conflict resolution. Interview on 8/4/09 at 3:30 pm with CNA "ZZ" revealed that when she was asked about what training she had received related to abuse and neglect, she indicated that she had not received any training at this facility. She further revealed that she had been employed for four (4) months. Interview on 8/4/09 at 3:35 pm with CNA "XX" revealed that she has not had any training regarding abuse and that she had not received any facility orientation. She was unaware of who in the facility was responsible for abuse prevention. She further revealed that she had been working for four (4) days. Interview on 8/4/09 at 4:15 pm with the Staff Development Coordinator revealed that she had been at the facility for three (3) weeks and had not conducted any inservices. She further revealed that the facility policy is to teach abuse training during orientation Interview on 8/5/09 at 8:30 am with the Director of Health Services revealed that the last three (3) employees hired and currently working had not had any orientation or abuse training. During review of abuse investigations conducted by the facility and reported to the state agency, revealed two (2) incidents of residents allegations of verbal abuse by CNAs | 2014-04-01 | ||
| 10569 | 10569 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 333 | D | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and review of the Medication Adminisrtation Record (MAR) the facility failed to administer [MEDICATION NAME] according to physician's orders for one (1) resident (#1) on a sample of twenty one (21) residents. The findings include: Review of the clinical record for resident #1 revealed that on 7/23/09 the [MEDICATION NAME] was changed from 100 milligrams (mgs.) two (2) capsules twice a day (b.i.d.)to [MEDICATION NAME] 4mgs (100mgs) suspension per tube every six (6) hours (q6h). The resident has a history of [MEDICAL CONDITION] disorder according to the facility's admission history and physical. Review of the July 2009 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The July MAR indicated [REDACTED]. Further review of the July MAR indicated [REDACTED]. Further review of the medical record revealed a physician's order dated 7/26/09 to "increase [MEDICATION NAME] to 100mgs three times a day (t.i.d.). The July MAR indicated [REDACTED].i.d. with the times of administration as 9am, 3pm, and 9pm. The dates that for administration are 7/23/09 to 7/31/09. There is no evidence that the [MEDICATION NAME] was given on the following dates and times: 7/24 at 9am and 3pm; 7/26 at 9am; and 7/31 at 9am and 3pm. Record review revealed a nurses' note dated 8/3/09 that the physician's and responsible party were notified of the missed [MEDICATION NAME] dosages. The physician ordered a [MEDICATION NAME] level. The results of the [MEDICATION NAME] level was 2.5 ml, which was below the normal range of 10.0 - 20.0. The physician was notified of of this results and ordered the [MEDICATION NAME] be changed to 100mgs every am (Qam), and every pm (Qpm) and 200mgs at bedtime (Qhs). | 2014-04-01 | ||
| 10570 | 10570 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 514 | E | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to ensure that physician's progress notes were in the resident's medical record for ten (10) residents (#3, #4, #6, #7, #8, #9, #10, #15, #16, and #20) and that physician's orders [REDACTED]. Findings include: 1. Record reviews for residents #3,#4, #6, #7, #8, #9, #10, #15, #16, and #20 revealed missing physician's progress notes. Interview on 8/4/09 at 3:40 pm with the physician revealed that there has been a problem with progress notes missing from resident's medical records. The physician indicated that she brings her progress notes and facility staff is suppose to place the notes in the residents' records. She further indicated that she has had problems with missing progress notes since October 2008. Interview of 8/5/09 at 9:45 am with the Director of Health Services revealed that the physician's progress notes were missing from resident's medical records. She further revealed that the physician's visits at least once a week but there are no progress notes and that medical records staff are responsible for placing progress notes in the records. 2. Record review for resident # 1 revealed that a [MEDICATION NAME] order written on 7/26/09 by a nurse indicated an "increase" in the [MEDICATION NAME] dose to 100mgs. three times a day (t.i.d.). Further record review revealed that on 7/23/09 the [MEDICATION NAME] was ordered 100mgs every six hours (q6h), which is four times a day. The order on 7/26/09 did not reflect an "increase" Review of the July 2009 MAR for resident #1 revealed that [MEDICATION NAME] is written as " [MEDICATION NAME] 4mls (100mgs) per tube q6h t.i.d. with hours of administration as 9am, 3pm, and 9pm. Every six hours (q6h) is not the same as t.i.d. During post survey review of the June 2009 MAR for resident #1 revealed that [MEDICATION NAME] two (2) capsules via tube twice a day (b.i.d) had been marked through and [MEDICATION NAME] 125 mgs/5mls. suspension 4 ml… | 2014-04-01 | ||
| 10488 | 10488 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2009-08-11 | 166 | E | 1 | 0 | U6FQ11 | Based on facility document review, staff interview, and resident interview, the facility failed to make prompt efforts to resolve a grievance relating to food temperatures for nine (9) Resident Council members who voiced complaints related to cold food in Resident Council meetings on 05/20/2009 and 06/09/2009, and for one (1) resident ("A") on the survey sample of five (5) residents. Findings include: Review of the Resident Council minutes of 05/20/2009 revealed that nine (9) residents complained that food was served cold. The response from the Dietary Manager on 05/21/2009 was to place plate covers on the food. However, review of the 06/09/2009 Resident Council meeting minutes revealed there continued to be resident complaints regarding cold food being served. There was no evidence to indicate that additional actions had been taken to address this problem. During an interview with Resident "A" conducted on 08/10/2009 at 3:30 p.m., Resident "A" acknowledged that food temperatures had been discussed in the Resident Council meetings, but that there had been little change. During an interview with the Dietary Manager (DM) conducted on 08/11/2009 at 8:29 a.m., she stated that she was at a loss as to how to keep food temperatures satisfactory for residents. Cross refer to F371. | 2014-07-01 |
| 10489 | 10489 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2009-08-11 | 371 | F | 1 | 0 | U6FQ11 | Based on observation, the facility failed to ensure that food items held on the residents' food service steam table were at or above 135 degrees Fahrenheit. The resident census was 153 residents. Findings include: During an observation of the facility's steam table conducted on 08/11/2009 at 8:20 a.m., oatmeal was 100 degrees Fahrenheit (F), eggs were 101 degrees F., and bacon was 101 degrees F. During a prior observation of the steam table conducted on 08/10/2009 at 5:19 p.m., staff were not able to calibrate the thermometer to obtain temperatures, and there was no other thermometer available to monitor temperatures. | 2014-07-01 |
| 10516 | 10516 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 504 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that laboratory tests were obtained as ordered for five residents (#5, #7, #18, #19 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 1/16/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 2. Resident #19 had a 1/21/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:45 a.m., licensed nurse "DD" stated that the additional laboratory tests performed for residents #18 and #19 were obtained in error and did not have a physician's orders [REDACTED]. 3. Resident #5 had a physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 4. Resident #7 had a Complete Metabolic Panel (CMP) obtained on 5/13/09 and 5/14/09. However, review of the resident's medical record revealed [REDACTED]. 5. Review of resident #20's closed record revealed a 3/30/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, nursing staff did not have a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:15 a.m., licensed nurse "CC" stated that the additional laboratory tests performed on residents #5 and #7 were obtained in error. Nursing staff did not have a physician's orders [REDACTED]. | 2014-04-01 | ||
| 10517 | 10517 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 325 | E | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician reviewed and addressed the registered dietician's recommendations timely for five residents (#6, #18, #19, #26 and #30), and failed to follow a physician's orders [REDACTED].#2) of 15 residents with weight loss from a total sample of 30 residents. Findings include: 1. Resident #18 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent in eating on the 4/1/09 Significant Change of Condition comprehensive assessment. He/She was on a Regular diet. Resident #18 had a 5/20/09 and 6/17/09 registered dietician's recommendation for 30 milliliters (ml) of protein supplement twice a day because of his/her significant weight loss of 10% in six months, a low [MEDICATION NAME] level and meal intake of less than 75%. Staff recorded the resident's weight as 188.8 pounds in May, 186.2 in June and 181.8 in July, 2009. The resident's [MEDICATION NAME] level on 6/1/09 was below normal at 18 (normal range, 20-40). However, despite the continued gradual weight loss and low [MEDICATION NAME] level, the resident's attending physician did not act on those recommendations until 7/21/09 (34 days later) at which time the physician ordered the protein supplement. 2. Resident #6 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent with eating on the 4/11/09 MDS assessment. Resident #6 had a 4/22/09 registered dietician's recommendation for fortified meals because of meal intake of less than 75%, a body mass index (BMI) of less than 19, having wounds, a low [MEDICATION NAME] and a low [MEDICATION NAME] level. The resident's 4/9/09 [MEDICATION NAME] level was 10.7 (normal range 20-40) and his/her [MEDICATION NAME] level was 3.0 (normal range 3.4-4.8). However, despite the decreased intake, the recorded BMI of less than 19, and the low [MEDICATION NAME] and [MEDICATION NAME] levels, the resident's … | 2014-04-01 | ||
| 10518 | 10518 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 282 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to implement the plan of care to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents. Findings include: Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. See F323 for additional information regarding resident #27. | 2014-04-01 | ||
| 10519 | 10519 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 428 | E | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician acted on the consultant pharmacist's recommendations in a timely manner for nine residents (#2, #3, #9, #18, #19, #20, #24, #27 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 7/30/09 consultant pharmacist recommendation to increase the dose of Stalevo to aid in reducing the potential of falls and to change the time of the resident's Flomax from morning to hour of sleep to reduce any orthostatic hypotension to aid in reducing falls. However, the physician did not act on those recommendations until 8/19/09, at which time he/she increased the dose of Stalevo and changed the time of administering of Flomax to bedtime. 2. Resident #19 had a 3/26/09 consultant pharmacist recommendation for a [DIAGNOSES REDACTED]. However, the physician did not act on that recommendation until 5/27/09, at which time he/she gave a [DIAGNOSES REDACTED]. 3. Resident #20 had a 7/30/09 consultant pharmacist recommendation for the resident's Miralax be mixed with 8 ounces of water or juice according to the manufacturer's recommendations instead of the 4 ounces of liquid that the nursing staff had been administering. However, the physician did not act on that recommendation until 8/18/09, at which time he/she ordered nursing staff to give the Miralax with 8 ounces of water or juice. The resident also had a 6/30/09 consultant pharmacist recommendation for a potassium replacement due to the resident receiving HCTZ daily without a potassium supplement. The resident's 6/30/09 potassium level was low at 3.1 (normal range 3.5-5.3). However, the physician did not act on that recommendation until 7/15/09, at which time, he/she ordered 20 miliequivalents (meq) of KDur daily. During an interview on 8/20/09 at 8:30 a.m., licensed nurse "DD" stated that the consultant pharmacist gave the recommendations to the D… | 2014-04-01 | ||
| 10520 | 10520 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 225 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to thoroughly investigate the past history of one of sixteen employees, and failed to report one injury of unknown origin to the State survey and certification agency. Findings include: 1. According to the 4/30/09 nurse's notes at 1:40 p.m., resident #12 had [MEDICAL CONDITION] and discoloration on his/her right hand, wrist and lower forearm, and complained of pain. The resident was sent to the emergency room (ER) for evaluation. It was determined that he/she did not have a fracture but had a contusion of the right wrist. Although the facility had investigated that injury and determined it had been of unknown origin, it was not reported to the State survey and certification agency. 2. Review of the personnel records for sixteen employees revealed that the facility hired an employee on 9/22/08. However, the facility failed to thoroughly investigate his/her history including having obtained a current criminal background check prior him/her working at the facility. On 8/20/09 at 1:00 p.m., the administrator stated that the facility staff were unable to locate the background check. | 2014-04-01 | ||
| 10521 | 10521 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 323 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to provide a chair alarm as planned to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents and failed to ensure that two handrails were secured to the wall on one unit (Unit IV) of five units in the facility. Findings include: 1. Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. On 8/20/09 at 12:50 p.m., certified nursing assistant "AA" confirmed that the resident did not have a chair alarm on his/her wheelchair. "AA" stated at that time that staff did not apply an alarm on the resident's wheelchair. On 8/20/09 at 12:55 p.m., licensed nursing staff "BB" stated that staff did not apply an alarm on the resident's wheelchair because, the resident did not attempt to get out of his/her wheelchair unassisted. However, according to the 7/15/09 at 9:10 p.m. nurses' notes, nursing staff had found the resident on the floor in his/her room next to his/her wheelchair. 2. During the General Observation Tour of the Facility on 8/20/09 at 11 a.m., two sections of handrails were loose in the Unit IV hall between the common bath and the residents' telephone room, and between rooms 442 and 440. | 2014-04-01 | ||
| 10522 | 10522 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 505 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to promptly notify the physician about an abnormally high [MEDICATION NAME]/INR level and an abnormally high BUN level for one resident (#3) from a sample of 30 residents. Findings include: Nursing staff had given 5 milligrams (mgs) of [MEDICATION NAME] daily to resident #3 since his/her admission on 6/9/09. Licensed nursing staff had obtained a [MEDICATION NAME]/INR blood level on the resident on 6/15/09. Although, the INR was abnormally high at 3.69 (therapeutic range was between 2.0 and 3.0), licensed nursing staff had failed to notify the physician about that result until 7/7/09 (22 days later). At that time, the physician ordered nursing staff to hold the [MEDICATION NAME] that day and then decrease the dose to 2.5 mgs and alternating that with 5 mgs every other day. On 8/19/09 at 11:00 a.m., the consultant pharmacist stated that licensed nursing staff should have notified the resident's physician about the abnormally high INR result prior to 7/7/09. Resident #3 had an abnormally high BUN level of 52 reported on 8/4/09. The normal range for a BUN level was between 7 and 18. Although the resident had an abnormally high BUN level of 31 on 6/6/09 prior to his/her admission to the facility on [DATE], there was no evidence that licensed nursing staff had notified the resident's physician about the even higher BUN result on 8/4/09. | 2014-04-01 | ||
| 10523 | 10523 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 253 | C | 3EK711 | Based on observations, it was determined that the facility failed to maintain an environment that was free from dust, rust, stains, missing baseboards, dirt, cobwebs and/or debris on all five hallways in the facility. Findings include: The following were observed on 8/18/09 between 8:55 a.m. and 11:00 a.m. and on 8/20/09 at 10:00 a.m. and 11:00 a.m. 500 Hall 1. There were rusty metal bedpan holders mounted on the bathroom walls in rooms 522 and 523. 2. There was a heavy build up of dust on the bathroom ceiling vents in rooms 523, 540, 541, 542, 543, 545 and 547. 3. There were rusty metal bases on the suction machines in rooms 512 and 541. 4. The laminate finish was peeling off of the side of the nightstand in room 544. 5. There were cobwebs on the furniture in room 531. 6. There was a dried brown liquid substance on the bathroom ceiling light fixtures in rooms 526 and 528. 7. The bathroom light fixture in room 526 was separated from the ceiling on two sides. 8. There was a Exelon medication patch dated 7/5/09 attached to the shower wall in room 521. 9. There were scuffs and gouges on the door of the common bath. 10. There was approximately a five foot section of baseboard missing in the dining area. 11. There was a section of baseboard missing in the hall next to the supply closet. 400 Hall 1. There were scuffs and paint peeling off of the wall next to the linen storage room. 2. There were scuffs and gouges on the door of the common bath. 3. The baseboards were scuffed and stained in the television area. 4. There were stains and paint peeling off of the bottom cabinets in the clean utility room. 300 Hall 1. There was a heavy build up of dust on the ceiling vents in rooms 310 and 331. 2. There were rusted out areas at the bottom of the bathroom door frames in rooms 313 and 331. 3. There were rusty grab bars in the bathrooms in rooms 315, 320 and 342. 4. There were dried brown stains on the bathroom ceiling in room 344. 5. There were dried brown splatter stains on the walls and ceiling of the soiled linen room. 6. … | 2014-04-01 | ||
| 10524 | 10524 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 368 | E | 3EK711 | Based on group interview and staff interview, it was determined that the facility failed to offer bedtime snacks to six of fourteen residents who attended the group interview. Findings include: During the group interview on 8/19/09 at 3:00 p.m., six of the fourteen residents said that they were not offered bedtime snacks. During interviews conducted on 8/20/09 between 8:20 a.m. and 9:00 a.m. with the six residents in the group interview who had reported not being offered bedtime snacks, they said that nursing staff did not offer them a bedtime snack on the previous evening (8/19/09). During an interview on 8/20/09 at 9:30 a.m., the Director of Nursing stated that bedtime snacks were kept stocked on the units and nursing staff was responsible for offering them to the residents. | 2014-04-01 | ||
| 10483 | 10483 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2009-08-25 | 492 | F | 1 | 0 | YU2J11 | Based on observation, interview and record review, the facility failed to have a current licensed nursing home administrator employed to manage the facility in the day to day operations as required by state law. Findings include: A report on August 17, 2009 received by the state survey agency reported that the facility had no licensed nursing home administrator currently employed. During an onsite investigation on August 25, 2009 there was no administer onsite or employed. An interview conducted at 1:00 p.m. with administrative nursing staff member "AA" confirmed that the facility had no licensed nursing home administrator currently employed. | 2014-07-01 |
| 10350 | 10350 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 309 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow physician's orders related to a bed/chair alarm and blood pressure parameters for two (2) residents (#5 and # 16) from a sample of twenty four (24) residents. Findings include: 1. Observation of resident #5 on 8/24/09 at 8:35 a.m. with Rehabilitation tech "YY" revealed the resident in bed with a sensor alarm on the bed and wheelchair. Observation of incontinence care provided by Certified Nursing Assistant (CNA) "XX" on 08/24/09 at 12:35 p.m. revealed that the bed alarm started sounding. The CNA turned it off and continued care. Review of the clinical record for resident #5 revealed a physician's order dated 8/18/09 to discontinue the bed/chair alarm. Continued review revealed an Interdisciplinary Progress Note dated 08/18/09 indicating that the bed/chair alarm had been discontinued. During interview, record review and observation with Unit Manager (UM) "ZZ" on 08/25/09 at 4:00 P.M., she acknowledged that the bed/chair alarm had not been discontinued as ordered by the physician. 2. Review of the clinical record for resident #16 revealed a [DIAGNOSES REDACTED]. Review of the June, July, and August, 2009 Medication Administration Records (MAR) revealed that the resident received the [MEDICATION NAME] fourteen (14) times when the SBP was less than 120. Interview on 08/26/09 at 11:10 a.m. with, Licensed Practical Nurse (LPN) Unit Manager "CC" revealed that the [MEDICATION NAME] was documented as given on the days it should have been held. | 2014-07-01 |
| 10351 | 10351 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 244 | D | 0 | 1 | 2MEL11 | Based on review of the Resident Council meeting minutes and residents and staff interview, the facility failed to actively work to resolve continued grievances related to timely response to call lights. Findings include: During a group interview on 08/25/09 at 10:00 a.m., eleven (11) of thirteen (13) residents in attendance revealed that they had ongoing problems with timely responses to call lights and that they had voiced these concerns to the facility during Resident Council meetings on more than one occasion. Eleven (11) residents revealed that although the average response time to a call light was about 15 minutes; response time could take 45 minutes or more and was l an ongoing problem. The group members revealed that the greatest concern was not with the initial response to the call light but with the Certified Nursing Assistants (CNA) entering the residents' rooms, turning off the call light, and informing the resident that the CNA would inform the assigned CNA to return to assist the resident. However,on these recalled occasions no one would return. The residents indicated that either ultimately no one followed up with them or that, after long waits, the residents turned the light on again and repeated the process. During an interview with random resident "B", assessed as cognitively intact, on 08/26/09 at 9:00 a.m., he/she revealed that the call light concern had come up more than a few times at the Resident Council meetings and could not recall any specific response from the facility to address the problem about lights being turned off without assistance and follow up care. During an interview with the Activities Director on 08/26/09 at 1:30 p.m., she revealed that she attended and took minutes at each meeting for the residents. She revealed that she recalled that the subject of call light response had come up several times over the last six months during the Resident Council meetings. She cited examples of complaints about a call light on the floor for one resident's roommate and complaints on more th… | 2014-07-01 |
| 10352 | 10352 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 322 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that the appropriate amount of flush/water was administered per Gastrostomy Tube as ordered by the physician for one (1) randomly observed resident during Medication Pass. Findings include: During and observation of Medication Pass on 08/25/09 at 9:01 a.m., Registered Nurse (RN) "JJ", flushed a gastrostomy tube ([DEVICE]) with 120 milliliters (ml) of water after having checked for residual and placement of the tube. Interview on 8/25/09 at 9:01 a.m. with RN "JJ" revealed that she had flushed the tube with 120ml of water. Review of the physician's orders [REDACTED]. Interview at 10:00 a.m. on 08/25/09 with RN "JJ" revealed that she needed to give the resident 230ml more water for hydration purposes. | 2014-07-01 |
| 10353 | 10353 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 441 | D | 0 | 1 | 2MEL11 | Based on observation and staff interview the facility failed to maintain an environment free of the likelihood of infection for one (1) randomly observed resident during Medication Pass. Findings include: Observation during Medication Pass on 08/25/09 at 10:30 a.m. revealed Registered Nurse (RN) "JJ" administering medication to the resident by spoon. After administering a spoonful of pills to the resident the placed the cup of pills with the spoon inside onto the unclean, uncovered bedside table, so that she could give the resident some water. As she began to pick the cup up with the spoon in it, an orange capsule fell out onto the unclean bedside table. "JJ" scooped it up with the spoon, put it back into the cup with the other pills and continued to administer them to the resident. Interview with Licensed Practical Nurse (LPN), Unit Manager "CC" on 08/25/09 at 10:35 a.m. revealed that since it was a orange capsule and easily identifiable it should have been discarded and replaced. It should not have been administered to the resident after it fell on an unclean surface. | 2014-07-01 |
| 10354 | 10354 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 315 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, failed to perform incontinence care in a manner to prevent urinary tract infection [MEDICAL CONDITION] for one (1) resident ( #9) from a sample size of twenty-four (24) residents. Findings include: Observation of incontinence care for resident #9 on 08/25/09 at:28 a.m. provided by Certified Nursing Assistant (CNA) "GG" assisted by Licensed Practical Nurse (LPN) "FF" revealed the CNA used the same disposable wipe a total of seventeen (17) [MEDICAL CONDITION] up and down the right inner thigh and then wiped the middle labia without changing the wipe. The CNA obtained a new wipe and wiped twenty-four (24) [MEDICAL CONDITION] on the left inner thigh and then cleaned the inner vaginal area without rearranging or obtaining a new wipe. The resident was repositioned on his/her left side and after the CNA obtained a new wipe,she wiped repeatedly over the back area and around the open wound area on the gluteal fold using the same wipe. During an interview with CNA "GG" on 08/25/09 at 10:15 a.m. she revealed that she had recently attended inservices on incontinence care. Review of the facility 's policy and inservices on perineal care revealed that for females the labia should be gently separated using downward [MEDICAL CONDITION] from the pubic to rectal area using alternate sites of the cloth with each downward stroke. | 2014-07-01 |
| 10355 | 10355 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 156 | C | 0 | 1 | 2MEL11 | Based on record review and staff interview, the facility failed to ensure that liability and appeal notices for medicare non-coverage were provided for fifteen (15) of seventeen (17) resident records reviewed. This included thirteen (13) randomly-reviewed residents and two (2) residents (#6 and #10) from twenty four (24) sampled residents. Findings include: Review of residents discharged from Medicare services revealed seventeen (17) residents were identified by the facility as no longer meeting the criteria for skilled medicare services, all of whom were still in the facility. Continued review revealed only two (2) Notices of Medicare Provider Non-Coverage forms were located. Interview on 08/26/09 at 11:20 a.m. with the Administrator revealed that she was aware there was a problem with liability notices. Of the seventeen (17) residents discharged from Medicare services in the last three (30 months, only two (2) residents received non-coverage notices. Review of these two Notices revealed that there was no date as to when they had been sent, and no description of the services that were no longer covered. | 2014-07-01 |
| 10356 | 10356 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 502 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that laboratory specimens were drawn as ordered by the physician for one (1) resident (#9) of twenty -four (24) sampled residents. Findings include: Record review of resident #9 revealed [DIAGNOSES REDACTED]. Review of the physicians' orders revealed an order dated 07/25/09 for a [MEDICATION NAME] Time with International Ratio (PT with INR) every Monday and Thursday. Record review revealed no evidence that this laboratory test had been completed on Monday, 08/10/09 or Thursday, 08/13/09. During an interview with the Unit Manager Licensed Practical Nurse (LPN) "CC" on 08/24/09 at 3:45 p.m. she revealed, after checking her records and with the laboratory, that the [MEDICATION NAME] with INRs were not done as ordered. | 2014-07-01 |
| 10357 | 10357 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 279 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a plan of care for the use of [MEDICATION NAME] (a blood thinning medication) for one (1) resident (#4) of the twenty-four (24) sampled residents. Findings include: Review of the clinical record for resident #4 revealed a [DIAGNOSES REDACTED]. Further review of the clinical record revealed no evidence that a plan of care had been developed for the use of [MEDICATION NAME]. Interview with the Minimum Data Set (MDS) Coordinator on 8/24/09 at 1:56 p.m. revealed that there was no plan of care for [MEDICATION NAME] and indicated that there should have been one developed. | 2014-07-01 |
| 10434 | 10434 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 469 | F | 1 | 1 | FH9411 | Based on observation, review of facility records, and staff, resident and family interviews the facility failed to maintain an effective pest control program to remain free of flies in the facility's only dining room and on two (2) of two (2) units. Findings include: During an observation of the lunch meal for resident #14 on 8/25/09 at 8:15 a.m. a fly was noted on the resident's breakfast tray. It was also noted on a container of food which was later consumed by the resident. An observation of resident #18 on 8/26/09 at 12:30 p.m. revealed a fly on the resident's food tray. It was noted to land on the edge of a container of food which was being consumed by the resident. A fly swatter was observed at the bedside of the resident's roommate. In an interview with the Maintenance Supervisor on 8/26/09 at 2:00 p.m., he stated that he was not aware of an issue with flies until this past Monday. Review of the Pest Control record revealed that flies had not been identified as a problem for treatment during the July visit and again on the visit of 8/26/09. During a random observation of lunch in the main dining room on 8/24/09 beginning at 12:55 p.m. a fly was observed on the back of a resident's shirt. At 1:00 p.m. a fly was observed on the open milk carton of a random resident. At 1:15 p.m. the fly was still in the vicinity of this resident and was observed on the rim of the resident's juice glass and on the tip of the straw in the milk carton. The resident was observed to drink from both containers following the fly's presence. The fly was then observed on the beef stroganoff of the resident at the next table at 1:20 p.m. During a random observation of supper on 8/25/09 at 6:05 p.m. a fly was observed around a feeding table inside the door to the right. Four (4) resident's and one (1) Certified Nursing Assistant (CNA) were at the table. The CNA had to swat the fly away from two (2) of the resident's faces two (2) times and also swatted it away with her hands two (2) times from their food. One (1) of the resident's swat… | 2014-07-01 |
| 10435 | 10435 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 241 | D | 1 | 1 | FH9411 | Based on record review and staff interview the facility failed to promote care in an environment that enhances dignity and respect for one (1) resident "O" from twenty-four (24) sampled residents. Findings include: During an interview with Licensed Practical Nurse (LPN) "DD" on 8/26/09 at 10:45 a.m., he stated that he and resident "O" had a fair relationship during the time he had cared for the resident. He stated that he would do things that irritated the resident and the resident did things to irritate him. When asked what the resident did to irritate him, he stated that the resident would put the call light on for things that he could do for himself. An example would be when the resident called to ask him to get his remote control or nasal oxygen for him and they would be within the resident's reach. He said he would tell the resident where they were and ask him why didn't he get them for himself? He further stated that four or five months prior to the his death, the resident put his call light on and asked LPN "DD" to get his shoes for him. LPN "DD" said the resident asked for the house shoes that were in the seat of the wheelchair within the resident's reach. When he asked the resident why he asked him to get them when they were within the resident's reach, the resident replied that he just wanted the nurse to hand them to him. This LPN stated that he told the resident that we were not butlers or maids. The resident told him that he paid his salary and told him to leave his room. He stated that he called the resident's daughter and told her what he had said to the resident but he did not remember if he told any other staff. After he said this to the resident, LPN "DD" said that he should not have said that to the resident, he thought it was probably inappropriate. In an interview with the Risk Manager on 8/26/09 at 2:45 p.m., she stated that LPN "DD" had not told her what he had said to the resident in the past. In an interview with the Administrator on 8/26/09 at 4:30 p.m., she stated that she also was not … | 2014-07-01 |
| 10533 | 10533 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 225 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that injuries of unknown origin and allegations of abuse were immediately reported to the facility Administrator and to the State survey and certification agency, and that these allegations were thoroughly investigated for two residents (#1 and "A") of twenty four (24) sampled residents. Findings include: 1. Observation of resident #1 on 8/25/09 at 3:20 p.m. during a skin assessment revealed that Certified Nursing Assistants (CNA) "AA" and "BB" identified that the resident had an extensive, deep purple bruise between the fourth and fifth toe on the right foot. It extended behind the toes on the bottom of the foot and on the top of the foot. The CNA's indicated that they did not know how or when this injury occurred. They added that they discovered the bruise while getting the resident out of bed yesterday (8/24/09) and reported it to Licensed Practical Nurse (LPN) "DD" as soon as it was discovered. Record review revealed that there was no mention of the bruise in the nurses notes for 8/24/09. LPN "CC", the Unit Manager, located a Nurse/Physician Communication Record dated 8/24/09 included documentation of "Client has bruised area to right little toe area, ran over toe when rolling in wheel chair". This Communication Record was signed by LPN "DD". A telephone interview with LPN "DD"on 8/25/09 at 4:50 p.m. revealed that he had not witnessed the event but had been told by the Risk Manager that she had witnessed the event. An interview with the Risk Manager on 8/25/09 at 5:05 p.m. revealed that she had seen the resident with his foot behind the wheel of the wheelchair mid-morning on 8/24/09. She was aware that the CNA's had discovered the bruise before the resident got up for the morning on 8/24/09. She added, that she did not witness the resident's foot being run over with the wheel chair and acknowledged that this was an unwitnessed injury of unknown origin th… | 2014-04-01 | ||
| 10534 | 10534 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 279 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview the facility failed to develop a comprehensive care plan related to long-term symptoms affecting daily care for two (2) residents, ("A" and "B") of a sample of twenty-four (24) residents. Findings include: 1. During the initial tour conducted on 8/24/09 beginning at 11:00 a.m. the Unit Manager stated Resident "A" had difficulty swallowing and was going to have a procedure performed to stretch her esophagus. The Unit Manager further stated this difficulty had been a long term problem for the resident, but she had declined the procedure in the past. The resident, who was assessed as cognitively intact on the Minimum Data Set ((MDS) dated [DATE], stated she had difficulty swallowing, could only take small bites of food at a time, needed to have her throat stretched, and could not eat some foods during interviews on 8/24/09 at 1:05 p.m., 8/25/09 at 8:05 a.m. and 12:50 p.m. and 5:50 p.m. and again on 8/26/09 at 7:50 a.m. These conversations took place during meals in the main dining room. Each time the resident explained her difficulty and either was eating very little or asking for alternates. The Dietary Manager was interviewed on 8/26/09 at 11:00 a.m. and stated she was aware of the resident's problem with swallowing. She further stated, the resident's weight had been stable over the past year and that the resident would ask for foods that she could comfortably eat and that she frequently asked for alternates. Review of the Comprehensive Care Plan for the resident did not reveal any problem related to eating patterns or difficulty swallowing. The Care Plan Coordinator was interviewed on 8/26/09 at 9:05 a.m. She acknowledged she had not included this problem. 2. Record review for resident "B" revealed a current physician's orders [REDACTED]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of resident's care plan did … | 2014-04-01 | ||
| 10535 | 10535 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 280 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the Comprehensive Care Plan for one (1) resident, #3 of twenty-four (24) sampled residents related to the resident's desire to lose weight. Findings include: Review of the Comprehensive Care Plan for resident #3 revealed an update added 5/23/09 to a problem concerning the resident's risk for weight loss. The update revealed the resident actually desired to lose weight and that any weight loss would be planned and desired. However, the goals were not updated to reflect this and a current goal continued until the next review was to avoid significant weight loss. Review of interventions revealed the resident was also to continue receiving fortified foods twice a day. Review of the Minimum (MDS) data set [DATE] revealed the resident was on a planned weight change program. The Care Plan Coordinator and the Unit Coordinator were interviewed on 8/26/09 at 9:00 a.m. and both stated they were aware of the resident's desire to lose weight and acknowledged that the care plan was not revised with interventions to achieve this goal. | 2014-04-01 | ||
| 10536 | 10536 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 315 | D | FH9411 | Based on observation, record review and staff interview the facility failed to follow acceptable technique to prevent urinary tract infections during incontinent care for two (2) residents (#4 and #14) of twenty-four (24) sampled residents. Findings include: 1. On 8/25/09 at 9:30 a.m. Certified Nursing Assistant (CNA) "GG" was observed providing incontinence care to resident #4. The CNA used a perineal spray cleanser and washcloths. When the CNA cleaned the perineal area some of the perineal spray came in contact with the resident's skin. The resident protested . When the CNA turned the resident on her side to cleanse the anal area she wiped from the back to the front. Review of the facility's policy on Perineal Care revealed that washing should be performed from front to back. Review of the clinical record for this resident revealed laboratory reports dated 8/04/09 and 8/22/09 for urine cultures and sensitivities. Both revealed a urinary tract infection and the infecting organism was Escherichia coli. The resident was treated on both occasions with antibiotic therapy. 2. Record review for resident #14 revealed the resident was assessed on the 6/24/09 Minimum Data Set as being incontinent of bowel/bladder and as being dependent on staff for assistance of activities of daily living and as having a history of urinary tract infections. An observation on 8/24/09 at 4:00 p.m. revealed two Certified Nursing Assistants were leaving the resident's room. Certified Nursing Assistants (CNA) "HH" and "II" assisted the resident to the bathroom to provide incontinence care. A soiled brief was removed as the resident had been incontinent of bowel and bladder. Using a clean washcloth, the resident's perineal area was cleaned of feces by wiping one time with a back to front motion. A second clean washcloth was used to wipe the resident at mid perineum toward the back. The resident began urinating and was seated back on the toilet seat. Urine and a small amount of feces was noted on top of the toilet seat as the resident sat back … | 2014-04-01 | ||
| 10537 | 10537 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 325 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to put interventions in place to address the protein needs of one (1) resident (#5) of twenty-four (24) sampled residents. Findings include: Review of the clinical record for resident #5 revealed blood was drawn on 7/30/09 to determine the resident's protein levels. The results of the test indicated the resident's [MEDICATION NAME] and [MEDICATION NAME] levels were below the normal range. The physician ordered a repeat test in eight (8) weeks and a nutrition consult with the Registered Dietician (RD). Review of the Nutritional Progress Notes revealed the RD completed the consult on 7/31/09. No new interventions were recommended to address the low protein levels. The RD documented interventions were already in place. Review of the clinical record revealed the resident had been on fortified foods at all meals since 5/22/09. Review of the resident's current Comprehensive Care Plan revealed a new problem added 8/10/09 addressing the resident's recent six (6) month significant weight loss of ten point five percent (10.5%). Although the family states the weight loss was desirable and put the resident at her usual weight, low [MEDICATION NAME] levels put the resident at risk if further weight is lost. The Care Plan did not address interventions to specifically address the low protein. The Unit Manager was interviewed on 8/26/09 at 8:40 a.m. and stated residents with nutritional risk are discussed at weekly Standards of Care (SOC) meetings. Review of the Nurses' Notes revealed the resident was discussed at these meetings on 8/03/09, 8/13/09 and 8/20/09. There were no interventions discussed at these meetings to address the protein levels. The Unit Manager stated the RD does not attend these meetings. Nutritional concerns are referred verbally to the dietician as needed. The Dietary Manager was interviewed on 8/2/609 at 6:30 p.m. She stated fortified foods do not contain added protein. | 2014-04-01 | ||
| 10538 | 10538 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 332 | E | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain an error rate of less than five (5) percent. During observation of medication pass on 8/25/09 between 8:30 a.m. and 10:45 a.m. two (2) nurses were observed, during forty five (45) opportunities to pass medications. Four (4) errors were observed on one (1) of two (2) units resulting in a medication error rate of 8.88%. Findings include: 1. Licensed Practical Nurse (LPN) "JJ" administered two (2) puffs of [MEDICATION NAME] Multidose Inhaler to a resident. The second puff was administered ten (10) seconds after the first puff. In an interview with the LPN "JJ" at 8:40 a.m. she acknowledged that she should have waited two (2) minutes between puffs. A review of the facility's policy for administration of Oral Inhalations confirmed that two (2) minutes should elapse before administering the second puff. 2. LPN "KK" administered two (2) puffs of [MEDICATION NAME] Multidose Inhaler. The first and second puff was administered three (3) seconds apart. In an interview with this LPN she acknowledged that she should have waited at least one (1) minute between puffs. 3 & 4. Record review for the same resident revealed a physician's orders [REDACTED]. In an interview with LPN "KK" she confirmed that these two medications were omitted. | 2014-04-01 | ||
| 10539 | 10539 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 161 | E | FH9411 | Based on record review and staff interview, the facility failed to purchase a surety bond of sufficient value to assure the security of all resident trust funds deposited with the facility for 87 of 87 managed accounts. Findings include: Record review revealed the current surety bond was in the amount of $35,000.00. A review of bank statements for the Resident Trust Account revealed balances that exceeded this amount for the following months: 1. February 2009: 4 days were over the bond amount, the highest was $37,098.40 2. March 2009: 9 days over, the highest balance was $39,791.69 3. April 2009: 6 days over, the highest balance was $37,698.48 4. May 2009: The average daily balance was over the bond amount. 5. June 2009: The average daily balance was over the bond amount. 6. July 2009: The average daily balance was over the bond amount. Interview on 8/25/09 at 3:00 p.m. with the Business Office Manager revealed that she did not know the amount of the surety bond or that the account balance exceeded the bond amount. | 2014-04-01 | ||
| 10540 | 10540 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 365 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide liquids and food prepared to the consistency ordered by the physician for one (1) resident (#17) of a sample of twenty-four (24) residents. Findings include: Observation of the lunch service on 8/26/09 at 12:55 p.m. revealed resident #17 was served two (2) bowls of chili for residents on a regular diet. Review of the resident's current Physician order [REDACTED]. The Dietary Manager was interviewed on 8/26/09 at 2:15 p.m. and confirmed that the resident should have been served the pureed chili. Observation on 8/25/09 at 9:15 a.m. during medication pass revealed that a medication nurse administered medications to resident #17 with liquids that were not thickened. Review of the August 2009 physician's orders [REDACTED]. Observation in the resident's room revealed an image of a bumble bee over the resident's bed. Interview with Licensed Practical Nurse (LPN) "LL" on 8/26/09 at 10:00 a.m. confirmed that the image of the bumble bee is a reminder to staff to provide thickened liquids to the resident. She added, that the medication nurse should have given the medications with thickened liquids. | 2014-04-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );